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Principles and Practice 



OF 



Filling Teeth. 



BY 



C. N. JOHNSON, M.A., LD.S., D.D.S., 

PROFESSOR OF OPERATIVE DENTISTRY IN THE CHICAGO COLLEGE 
OF DENTAL SURGERY. 



WITH ILLUSTRATIONS. 



SECOND EDITION, REVISED AND ENLARGED. 



PHILADELPHIA: 

THE S. S. WHITE DENTAL MFG. CO. 

LONDON : 

CLAUDIUS ASH & SONS (Limitei)). 
1902. 






Copyright, igoo, by C. N. Xohnson 
Copyright, 1902, by C. N. Johnson. 
Entered at Stationers' Hall, London. 



PREFACE TO THE SECOND EDITIOK 



1 HE rapidity with which the first edition of this book was ex- 
hausted would seem to have left little opportunity for an extended 
re\4sion. An author must needs get somewhat away from the 
atmosphere of his work before he can critically study its defects 
and relieve it of its original crudities. It was with this feeling that 
the author approached the task of revising this book for the second 
edition, and he had supposed that accordingly there would be 
small chance for material change in the text, but he had not gone 
far without realizing that almost every page required some altera- 
tion and that several chapters had to be practically re-written. 
This is only in accordance with the rapid evolution of thought 
upon this important subject, and it is a healthy sign of the progress 
of the profession when an author finds his work, however con- 
scientiously written, so soon out of date. This applies, of course, 
more to the details than to the fundamentals of the subject, though 
it must not be forgotten that the varying changes in the details 
must eventually affect the fundamentals. The present edition is 
sent out WTith the realization that it is not free from the usual 
limitations of authorship, and yet it is the best of which the author 
is capable at the present time. He can only bespeak for it the 
same cordial reception that was generously given the first edition 
— a reception which has placed him beyond measure a debtor to 

the profession at large. 

C. N. J. 

Chicago, .Tune, 1002. 



COKTEISTS. 



PAGE 

INTRODUCTOEY 7 

CHAPTER 1 11 

Deposits ox the Teeth. Kinds of Deposits. — Salivary Calculus. — 
Serumal Calculus. — Stains on the Teeth. Removal of Deposits. Re- 
moval of Salivary Calculus. — Instruments for this purpose.— Technique 
of the Operation. — Removal of Serumal Calculus — Removal of Stains 
from the Teeth. — Instructions to Patients as to the Care of the Teeth. 
CHAPTER II 33 

DfiNTAL Caries. 
CHAPTER III 4G 

Examination of the Teeth for Caries. Appliances for Exam- 
ining the Teeth. 
CHAPTER IV 49 

Exclusion of Moisture During Operations. Kinds of Rubber 
Dam. — Size of Dam. — Punching the Holes in Rubber Dam. — Rubber- 
Dam Clamps. — Kinds of Clamps. — Clamps for Molars and Bicuspids. — 
Cervical Clamps for Buccal, Labial, or Lingual Cavities. — Ligntures — 
Manner of Applying the Dam in the Different Locations in the Mouth. — 
Applj'ing the Dam for Operations on Buccal, Labial, or Lingual Cavi- 
ties. — Application of Dam in Difficult Cases. — Use of Napkins and Cot- 
ton Rolls for Maintaining Dryness During Operations. 
CHAPTER V 83 

Classification and Preparation of Cavities. Cavity Prepa- 
ration. Simple Proximal Cavities in Incisors and Cuspids. — Separating 
the Teeth. — Detail of Cavity Formation. — General Considerations. — 
Proximal Cavities in Anterior Teeth Involving the Incisal Angle. — Detail 
of Cavity Formation. — General Considerations. — Proximal Cavities in Bi- 
cuspids and Molars. — Simple Proximal Cavities not Involving other 
Surfaces. — Proximo-Occlu.sal Cavities in Bicuspids and Molars. — The In- 
terproximal Space. — Separating the Teeth. — Details of Cavity Formation. 
— General Considerations. — Buccal, Labial, or Lingual Cavities. — Occlu- 
sal Cavities in Bicu.-^pids and Molars. — The Treatment of Softened Dentine 
in Deep-Seated Cavities. — Hypersensitive Dentine. 
CHAPTER VI IM 

Filling-Matekials. Gold and its Conibinutions. — Gokl and Plati- 
num. — Gold and Tin. — Gold and Iridium. — Amalgam. — Tin. — Cements. 
— Gutta-Percha. — Inlaj-s. 

CHAPTER VII 168 

Gold. Cohesive and Non-Cohesive Gold. — Annealing Gold. — Difier- 
ent Forms of Gold. — Crystal Golds. 

CHAPTER VIII 170 

Mallets and Malleting. The Hand Mallet. — The Automatic 
Mallet. — The Rapid Mallets. — Hand Pre-sure. — Pnjtection to the l*eri- 
denta! .Membrane in .Malleting. 

5 



Q CONTENTS. 

PAGE 

CHAPTER IX 193 

The Introduction, Condensation, and Finishing of Gold Fill- 
ings IN THE Different Classes of Cavities. Simple Proximal Gold 
Fillings in Incisors. — Pluggers. — Finishing Proximal Fillings in Incis- 
ors. — Proximal Fillings in Anterior Teeth Involving the Incisal Angle. 
— Fillings in Proximo-Occlusal Cavities in Bicuspids and Molars. — The 
Matrix. — Disto-Occlusal Fillings in Left Lower Bicuspids and Molars. — 
Pluggers. ^Finishing Fillings. — Disto-Occlusal Fillings in Plight Lower 
Bicuspids and Molars. — Disto-Occlusal Fillings in Upper Bicuspids and 
Molars. — Mesio-Occlusal Fillings in Bicuspids and Molars. — Occlusal 
Fillings in Bicuspids and Molars. — Buccal, Labial, or Lingual Fillings. 

CHAPTEPv X 229 

Manipulation of Platinum and Gold in Filling Teeth. 

CHAPTEPv XI 231 

Manipulation of Tin and Gold. 

CHAPTER XII 235 

Manipulation of Amalgam. Method of Packing Amalgam. 

CHAPTER XIII 239 

Manipulation of Cements. 

CHAPTER XIY 242 

Manipulation of Gutta-Percha. 

CHAPTER XV 243 

Making Inlay Fillings. Porcelain Inlays. — Fitting the Matrix. — 
Taking an Impression of the Cavity. — Adapting the Matrix to the Cavity 
in the Tooth. — Porcelain Bodies. — Matching Shades. — Baking the Porce- 
lain. — Gold Inlays. 
CHAPTER X YI 254 

Pulp-Capping. Materials for Capping Pulps. — Method of Capping 
Pulps. 

CHAPTER XVII 260 

Destruction of the Pulp. Destroying the Pulp with Arsenic. — 
Removing the Pulp with Cocaine. — Removal of the Pulp. 

CHAPTER XVIII 268 

Filling Pulp-Canals. 

CHAPTER XIX 271 

The Treatment of Pulpless Teeth. Treatment of Pulpless Teeth 
where the Canals have long been Exposed to the Fluids of the Mouth, but 
where there is no Fistulous Opening. — Treatment of Pulpless Teeth having 
a Fistulous Opening on Gum. — Opening into Filled Teeth in which 
Pulps have Died, but Lain Dormant. — Management of Pulpless Teeth in 
Anterior Part of Mouth to Prevent Discoloration. — Bleaching Teeth. 

CHAPTER XX 283 

The Management or Children's Teeth. Management of the 
Deciduous Teeth. — Treatment of Exposed Pulps in Deciduous Teeth. — • 
Treatment of Abscessed Deciduous Teeth. — The Management of Perma- 
nent Teeth in Childhood. 



II^TEODUOTORY. 



The problem of preventing or controlling caries of the teeth is 
one which enters very materially into the health, longevity, and 
happiness of the hnman race. Apparently we are not yet able to 
prevent decay, and it thus becomes imperative that we study the 
best means of checking and controlling it. When caries occurs 
on any surface of a tooth the dentist should study carefully the 
conditions which brought it about, and should aim in his operations 
so to change those conditions that caries will not be likely to recur. 

Too many practitioners are in the habit of following their work 
day after day in a thoughtless, slip-shod manner, without due con- 
sideration of the principles which should underlie all operative 
procedures, and without a proper study of the relations of cause 
and effect. When failures occur, as they do in the hands of all 
practitioners, — some more, some less, — the most profitable lesson 
is not always learned thereby. ISTo dentist should allow himself 
to pass over any failure, whether his own or another's, without 
carefully studying the particular reasons for that failure and the 
problems which must be solved to avoid a repetition in the future. 
With the clearness of vision which should eventually result from 
this kind of study the practitioner will be better equipped to serve 
his patrons, and his failures will grow perceptibly fewer. If all 
dentists would bring to their work a due regard for this form of 
observation, it would add materially to the permanence of dental 
service. 

7 



b INTRODUCTORY. 

In the consideration of the present subject the principal aim will 
be to direct attention to some of the causes of failure in filling 
teeth, and to offer suggestions relative to possible improvement in 
methods of procedure. In doing this no originality of treatment 
is claimed. The thought of the profession in recent years has 
been too active along these lines for any one individual to claim 
much in the way of originality. But some of the recent advances 
in practice would seem to need systematizing, and most of them 
require emphasizing. This is the present aim. 

The plan is to treat the various topics as nearly as practicable in 
the order of their performance in the mouth; to give in detail the 
consecutive steps of the operation, and to say something of the 
technique of the subject. This latter is considered to be of very 
great importance, but it is a matter quite difficult of intelligent 
treatment. The proper selection and use of instruments has much 
to do with the effectiveness of our work and the comfort of our 
patients, but the personal equation of each individual operator 
enters so prominently into the question that it is difficult to lay 
down rules for all to follow. Then, again, there is such a varia- 
tion in patients with regard to their toleration of different instru- 
ments that it is not always judicious to use the same instruments in 
the same way on all patients. We must study carefully this sus- 
ceptibility of our patients, and in all cases where it will not inter- 
fere with the perfection of our work we should respect their 
preference. Some individuals will submit to the use of hand 
instruments, such as excavators and chisels, with better grace than 
they will to the engine, while very many prefer the smooth, light 
touch of a rapidly-revolving bur to the g-rating, rasping sensation 
of an excavator. In the routine practice of operating there are 
some stages of the work where the engine is clearly indicated, and 
some where hand instruments must be used, but the predominance 



INTKODUCTOKY. 9 

of the use of either may in certain instances be determined by the 
patient. ISTot that we should in any sense allow patients to dictate 
to lis how we shall operate, but that we may often profitably study 
their varying susceptibilities to the impressions made upon them 
by different instruments, and govern our manipulation somewhat 
thereby. 

Much in the Avay of prejudice may be overcome by the invaria- 
ble use of keen, sharp instruments and a dextrous, careful method 
of manipulation. This applies as well to the engine as to hand 
instruments. The dentist should cultivate the utmost delicacy of 
touch, so as to impress upon his patient at all times the fact that 
he is giving the least possible discomfort commensurate with effec- 
tive work. 

The system of technique here suggested is not presented as 
being applicable to all operators or all patients. It is not even 
claimed that it is the best system, but merely that it is an attempt 
to formulate a definite and consecutive method of procedure in the 
performance of many of our operations, which in the past seem, 
for the most part, to have been performed without method and 
without system. 



Principles and Practice of Filling Teeth. 



CHAPTEK I. 

DEPOSITS ON THE TEETH. 

The first duty of the dentist when a patient applies to him for 
attention to the natural teeth is the thorough removal of all 
deposits, provided the patient is not suffering pain. In every 
instance where there is suffering the manifest duty of the profes- 
sional man is to relieve it at once if possible, no matter in what 
form it may present itself; but after this is accomplished, and 
before any filling operations are undertaken, the mouth should be 
put in as nearly a hygienic condition as may be secured by the ut- 
most cleanliness. It is too often the case that operators — some of 
them with a brilliant record as skillful manipulators — seem to ig- 
nore this important procedure, and hasten to the insertion of fill- 
ings in teeth covered with calculus. It matters not how beautiful 
or how perfect an operation may be under these conditions, the 
work should never be considered as ideal dental service. ISTo suc- 
cessful architect ever builds a house without first looking well to 
the foundation, and no surgeon of repute will proceed to operate 
upon a wound without at least making the surrounding parts as 
Ileal thy as may be in advance. Dentists are not living up to the 
highest possibilities of their art when they fail to consider the im- 
portance of maintaining the tissues around the teeth in a state of 
health, and this cannot be done short of a careful removal of all 
extraneous material which may be found adherent to the teeth. 
It is not within the province of the present work to go minutely 
into the pathology of this subject, and yet it would seem desirable 



12 



PKINCIPLES AND PKACTICE OF FILLING TEETH. 



to briefly indicate some of the deleterious effects produced by de- 
posits when allowed to remain. 

The encroachment of calculus along the neck and root of a 
tooth, if left unchecked, results in an absorption of the gum, the 
peridental membrane, and even the alveolar process, so that 
finally the support of the tooth is destroyed, and it is allowed to 
topple over and fall out. It is estimated by many observant prac- 
titioners that more teeth are lost as the result of diseased conditions 
in the tissues surrounding them than from decay of the teeth 
themselves; and, if this be true, it is very important that dentists 
should pay especial attention to the agencies calculated to bring 
^bout such conditions. It is undeniably a fact that calculus in a 
mouth subject to its continual formation will, if allowed to 
accumulate, sooner or later work the destruction of the teeth. 



Fig. 1. 



Fig. 2. 



Fig. 3. 




Figs. 1, 2, and 3 illustrate some extreme cases of calculus 
formation about the teeth. Figs. 1 and 2 show the mesial and 
distal aspects of two lower incisors with calculus attached, actual 
size. Fig. 3 is a mass of calculus detached from the buccal sur- 
face of an upper molar. The patient applied to her dentist for 
examination relative to some "growth" which she said was forming 
in her mouth, and the result was the removal of this piece of 
calculus, here reproduced in two views, actual size. It must be 
apparent that in the specimens shown the teeth need not neces- 
sarily have been lost if early attention had been given to these 
deposits. There was not the slightest indication of caries upon 
any of them, and it is safe to conclude that had the patients sought 



DKPOSITS ON THE TEETH. 13 

and obtained proper dental service in the initial stages of the 
affection the teeth might have been preserved for many years of 
usefnlness. It is true that in these particular cases the patient 
had failed to apply to the dentist in time to accomplish anything, 
through an ignorance of the significance of the deposits, and yet 
there would seem to be many instances where the neglect is not 
entirely traceable to the patient. It should be the office of the 
dentist not only to perform operations on the teeth, but to so 
educate those who come under his charge that the general public 
shall be made familiar with conditions so readily understood as 
these, and so manifestly self-evident when attentioji is once called 
to them. 

KINDS OF DEPOSITS. 

Deposits are usually classified under three kinds, salivary calcu- 
lus, serumal calculus, and green stain, though from an operative 
point of view the latter would seem to be widely distinguishable 
from the other two. It is not a deposit of appreciable bulk, and 
it is entirely different in character, both as regards its deleterious 
effects and the methods to be employed in its removal. ISTor 
would it seem to be altogether appropriate to limit the term to 
"green" stain. There are other stains on the teeth besides those 
of a green color, and they should not be ignored in considering 
the subject. 

Salivary Calculus. 

This, as its name implies, is chiefly a deposit from the saliva. 
The solid constituents of this secretion, which are normally held 
in solution during its progress from the gland to the mouth, be- 
come so affected by the change of environment on entering the 
oral cavity as to be precipitated in the form' of calculus on the 
teeth. This being true, we should naturally expect to find the 
most extensive deposits upon the surfaces of the teeth lying nearest 
to the openings of the salivary ducts, a fact borne out by clinical 
observations. The usual points of initial deposit of salivary calcu- 
lus are upon the lingual surfaces of the lower incisors, opposite the 
openings of the ducts from the sublingual and submaxillary glands,. 



14 PRINCIPLES A]^D PRACTICE OF EILLHSTG TEETH. 

and upon tlie buccal surfaces of the upper molars, which are 
copiously bathed in the parotid saliva. This must not imply that 
these are the only surfaces subject to the deposition of salivary 
calculus. There is no surface of any tooth exposed to the fluids 
of the mouth which may not accumulate this deposit, provided 
there is an absence of friction on that surface. 

The full function of mastication would seem to be one of the 
most effectual natural processes in limiting the deposition of 
salivary calculus, it being plainly evident to an observant operator 
the moment he looks into a mouth where mastication is confined 
to one side. It will invariably be found that the teeth on the 
unused side will present an altogether neglected appearance, and if 
there is a predisposition to the formation of calculus they will be 
almost completely covered with it, even over the occlusal surfaces. 
A striking object-lesson may be given patients as to the necessity 
of keeping the teeth in active and uniform service by calling 
attention to the difference in appearance of the teeth on the two 
sides, and impressing them with the fact that wherever, for any 
reason, thorough mastication is impracticable the deficiency should 
be supplied by substituting artificial friction with the tooth-brush. 
The demand for friction relates as well to the gums as to the 
teeth, it being very exceptional to find a healthy condition of the 
gums in any locality not subjected to full functional use. 

This question of giving the teeth and gums adequate employ- 
ment should be carefully studied by operators, and its necessity 
forced upon the attention of patients. It is the keynote of health 
in the mouth, as elsewhere in the human body, and it should be 
the prime function of the dentist to keep the oral tissues healthy. 
It is infinitely a higher aim to prevent disease than to cure it, and 
if dentists take this matter seriously to heart they can accomplish 
much in this direction. A critical study should be made of the 
conditions present in every mouth coming under the operator's 
attention, and a careful note made of the various landmarks of 
neglect. The results of this neglect must invariably be pointed 
out to the patient, and an impression made in such a manner that 
it cannot be ignored. If the dentist thereby fails to enlist the 



DEPOSITS ON THE TEETH. 15 

co-operation of his patient, it is only common justice to at once 
absolve himself from responsibility for the ultimate saving of the 
teeth. This will usually bring the patient to a proper realization 
of the true relation existing between operator and patient, and 
will at least establish an intelligent understanding between them. 

In character salivary calculus may vary from a soft granular 
mass, easily removed and disintegrated with an instrument, to a 
hard, dense, and almost flint-like consistence. This difference in 
density relates chiefly to the rapidity with which it is formed and 
the length of time it is allowed to remain in the mouth. When 
it is rapidly deposited and of recent formation it is comparatively 
soft, but seems to grow progressively harder if left undisturbed. 
The color also varies materially in different specimens, from a 
yellowish gray to a black, the former usually being associated 
with rapid and recent formations, while the latter is ordinarily 
confined to cases of long standing. In some mouths the yellowish 
gray remains almost indefinitely, so that the question of color is 
not entirely one of age ; and yet in specimens of extensive accumu- 
lation, such as those illustrated, it will usually be found that the 
portion neai-est the tooth, and also that immediately overlying the 
gum tissue, and which accordingly has been longest in place, is 
much darker than that more recently formed upon the surface. 

The present reference to color relates to a staining of the calcu- 
lus itself, and not to a surface deposit of black such as is commonly 
found in the mouths of smokers. The latter is a characteristic 
jet Ijlack discoloration, unmistakably from tobacco smoke, while 
the former is less intensely black, with sometimes a greenish tinge, 
— especially where it has been long in contact with the gum, — and 
its source is not so apparent. 

Serumal Calculus. 
This deposit is distinguishable from salivary calculus in several 
particulars, but chiefly in its initial point of location on the tooth. 
Salivary calculus finds its lodgment on that portion of the tooth 
which is bathed in saliva, and therefore becomes adherent to the 
crown or neck of the tooth, the part not covered by the gum. 



16 PKINCirLES AND PKACTICE OF FILLING TEETH. 

It may advance and force the gum and adjacent tissues back so 
as to follow the root to the apex, as in Tig. 1; and yet it begins 
not under the gum, but crownwise of it. Serumal calculus, on 
the contrary, attaches itself to the root of the tooth, or to that 
portion of the neck which is covered by the gum. The source of 
this deposit is therefore different from salivary calculus, and, as 
its name implies, it is supposed to be from the serum of the blood. 
In fact, it has sometimes on this account been termed sanguinary 
calculus, though it would appear that there are certain formations 
of this deposit which cannot well be considered as coming directly 
from the blood. In chronic alveolar abscess we often find upon 
the apex of a root which has been for some time constantly bathed 

Fig. 4. Fig. 5. 





in pus the characteristic serumal deposit. But it at least may 
safely be stated that serumal calculus is a deposit from the fluids 
which surround the root of the tooth, while salivary calculus is 
deposited from the fluids in contact with the crown. 

Another point of distinction between the two is found in the 
relative bulk of the deposit. Salivary calculus, as we have seen, 
may assume extensive proportions, while serumal calculus, on 
account of its environment, is restricted in growth, and is usually 
found in the form of small nodules, narrow bands, or thin scales 
(Figs. 4 and 5). These are ordinarily attached quite firmly to 
the surface of the root, and require considerable force to dislodge 
them. It is probable that the irritation produced by serumal 
calcuhis under the gums is accountable for many of the diseases 
to be found in the surrounding tissues, and which frequently lead 
to loss of the teeth, it being impossible to conceive of gums re- 
maining healthy with any considerable deposit of serumal calculus 
under them. 



DEPOSITS ON THE TEETH. l? 

The color of senimal calculus is usually darker than that of 
salivary calculus, and quite commonly has a greenish tinge run- 
ning through it. It is also dense in stritcture, and is probably 
formed more slowly than salivary calculus. It may be found in 
some instances deposited in a thin scale along the side of the root 
where the peridental membrane has been lost, or it may occur as 
small nodules, particularly at the apex of a root, as the result of 
chronic alveolar abscess. In other cases, where the attachment of 
the peridental membrane to the root seems perfect from the apex 
to near the alveolar border, but where the free margin of the gum 
is congested and puffed, a narrow band of calculus may be found 
encircling the neck of the tooth in its entire circumference just 
under the gum. This is sometimes so near the margin of the gum 
that it may readily be seen by forcing the gum back with a pledget 
of cotton. In any pocket formed between the gum and the root 
as the result of the loss of that portion of the peridental membrane, 
we may ordinarily expect to find more or less of a deposit of 
serumal calculus, and we need not hope to see the gum-tissue over- 
lying this become healthy so long as the deposit is allowed to 

remain. 

Stains on the Teeth. 

These may present themselves in varying degrees of extent and 
intensity, and in varying shades of color. The one claiming most 
attention from the profession in the past is green stain, which 
seems to occur with the greatest frequency on the labial surfaces 
of upper incisors in young patients. It may also be found in cer- 
tain instances coating the entire buccal and labial surfaces of all 
of the teeth in adults, though this is comparatively rare. It would 
appear strange that so much prominence has been given green 
stain to the almost complete ignoring of the other varieties. In 
point of frequency the brownish stains are more prevalent, and 
they are found occurring at all ages and upon any of the surfaces 
of the teeth not subjected to considerable friction, but it should bo 
stated in this connection that many of these brown stains will 
exhibit a greenish tinge when examined with a magnifying glass. 

All of the stains seem to form with the greatest intensity near 
the gum-margin, and gradually shade away toward the occlusal 



18 PRINCIPLES AND PRACTICE OF FILLING TEETH, 

surface, though in some instances thej constitute a more or less 
well-defined concentric band near the gingival line, following the 
curvature of the gum, and including the lingual as well as the 
labial surfaces. There is a wide variation in the degree of tenacity 
with which these stains adhere to the surfaces of the teeth ; in some 
instances the slightest friction being all that is necessary to remove 
them completely, while in others they seem almost part and parcel 
of the enamel itself. The green stains are usually more adherent 
than the brown, and in cases of great intensity of stain the surface 
of the enamel seems disintegrated and roughened after its removal. 
The indications in every instance are for the perfect polishing 
away of all such stains upon the teeth, the fact of their unsightli- 
ness being an all-sufficient reason for such a procedure outside of 
the somewhat undetermined point as to their possible deleterious 
effect upon the enamel. 

The origin of these stains seems not yet definitely settled. 
Various writers have advanced different theories upon the subject, 
probably the most noteworthy of which is that of Professor W. D. 
Miller in the Dental Cosmos, April, 1894. His conclusions seem 
to lead to the inference that the different stains are caused by 
different agencies, and that no one theory will account for all 
cases. In the light of the diversity of opinion expressed by 
writers upon this subject, it would appear unprofitable to consider 
it in detail at this time. 

Another variety of discoloration upon the teeth may be men- 
tioned as being distinct from the green and brown stains, and of a 
character entirely peculiar to itself. This is the black deposit 
caused by tobacco smoke. It may be found adherent to the teeth 
of smokers much the same as the other stains, except that it is 
more prevalent on the lingual surfaces, and it has more appreciable 
bulk. It may be scraped away with instruments, leaving the 
enamel apparently unaffected under it; but it does not accumulate 
like salivary calculus, so as to impinge upon the gum or cause irri- 
tation to the surrounding parts. In instances of the long-con- 
tinued use of tobacco the structure of the teeth themselves may 
become so stained as to permanently remain so, particularly where 
the enamel is gone and the dentine is exposed to the smoke. 



DEPOSITS ON THE TEETH. 19 

REMOVAL OF DEPOSITS. 
Removal of Salivary Calculus. 

There are two principal plans of manipulative procedure for the 
removal of salivary calculus, the push-cut method and the draw- 
cut method, each having different forms of instruments adapted 
to its use. By the push-cut method the blade of the scaler is 
brought to bear upon the calculus at the point nearest the occlusal 
surface of the tooth, and the mass dislodged by forcing the scaler 
between the calculus and the enamel in the direction of the root. 
By the draw-cut method the scaler is placed rootwise of the deposit, 
and force applied by pulling toward the occlusal surface. Each 
method has its advocates in the profession, and each is applicable 
to certain conditions, the best practice probably being to use them 
interchangeably, as circumstances suggest. The limitations of the 
draw-cut method relate to the fact that to force an instrument of 
sufficient size for the removal of salivary calculus far enough root- 
wise to seize the deposit frequently involves considerable impinge- 
ment on the gum, with consequent laceration ; while by the skillful 
use of the push-cut instrument the deposit may often be forced 
away without touching the gum at all. On the other hand, the 
push-cut method invites a certain danger which is never present 
with the draw-cut. The application of force directly toward the 
gum carries with it the constant possibility of the instrument 
slipping and wounding the gum, while a slip of the draw-cut instru- 
ment is comparatively harmless. The element of apprehension on 
the part of the patient when the push-cut is being used is some- 
times a menace which invites accidents from the patient flinching 
on the application of force, thus causing the instrument to glide 
into the gum. To avoid accidents of this nature, and to carry 
assurance to the mind of the patient, it is always necessary before 
applying any force with the scaler to so guard the hand of the 
operator against undue movement that the instrument, in case it 
does slip, will not be carried into the gum. This can be done by 
bracing the unused fingers — the ones not grasping the scaler — 
firmly against the occlusal surfaces of the teeth before applying 



20 PEIlSrCIPLES AND PRACTICE OF FILLING TEETH. 

the scaler to the deposit. By this means a perfect control may be 
maintained over the instrument, and a sense of security imparted 
to the patient which usually results in a reasonable degree of 
confidence during the operation. This matter of creating confi- 
dence on the part of the patient is an important element in con- 
ducting a successful practice in all lines of procedure, and the 
operator should study the manipulation of instruments to this end. 
The cardinal principles in operating should be precision of 
methods, firmness of control, and delicacy of execution. Patients 
are more susceptible to impressions made upon them through 
manipulative procedure than the average operator would seem to 
conceive of. They are quick to recognize superior skill in an 
operator by reason of his mastery of instruments and the apparent 
intelligence with which he approaches his work, and there are few 
operations in dentistry calling for a more diversified order of skill 
than the successful removal of calculus from the teeth. 

The cases are so varied in their nature, both as regards the 
extent and location of the deposit and also the character of the 
teeth and their position in the arch, that it may almost be said that 
each case constitutes a law unto itself, and must be approached in 
accordance with its individual requirements. And yet it would 
seem desirable to formulate so far as possible definite rules of 
procedure in this as in all other operations on the teeth, though 
the fact must constantly be borne in mind that in any formulation 
of this nature the element of personal equation must necessarily 
enter conspicuously into it and largely influence its details. 'No 
two men need be expected to approach this work in precisely the 
same way, though each should at least study out some systematic 
order of procedure for his own guidance, so as to accomplish the 
result in an orderly sequence, rather than by haphazard and slip- 
shod methods. Lack of system in the performance of our work 
has been one of our chief limitations as operators, and it is account- 
able for a grievous waste of time both to practitioner and patient. 

The methods here suggested are not applicable to all cases, nor 
will they probably appeal to all operators; but it is confidently 
hoped that they may at least prove helpful to those who in the 



DEPOSITS ON THE TEETH. 



21 



past have not thought it necessarj to employ any particnhir method 
in these operations. 

Instruments for the Removal of Calculus. 

The instruments here illustrated are largely adaptations from 
or modifications of the forms long since introduced to the profes- 
sion by various operators. Fig. 6 is a somewhat sickle-shaped 
contra-angle instrument, having three sides for cutting. It may 
therefore be used interchangeably as a push-cut or draw-cut instru- 
ment, though the sharpest or most acute edge being along the 
extremity of the instrument gives it greater efficiency as a push- 



FiG. Fio. Fig. Fig. Fig. 
11. 12. 13. 14. 15. 



Fig. 


Fig. 


Fig. 


Fig. 


Fk 


6. 


7. 


8. 


9. 


10 




out than as a draw-cut. Its uses will be indicated hereafter. 
Fig. 7 is an ordinary direct push-cut scaler, with the curvature 
somewhat nearer the cutting-edge than usual; while Fig. 8 is a 
long, slender, delicate instrument for reaching places inaccessible 
to Fig. 7. Figs. 9, 10, and 11, designed by Dr. A. G. Johnson, 
are hooked instruments of varying forms for draw-cut work along 
the roots of teeth in pockets under the gum. The distinguishing 
feature between these and the instruments generally suggested for 
this purpose relates to the reverse side of the scaler. Ordinarily 
the back of the scaler — the side coming in contact with the gum 
in passing between it and the root — is left with sharp angles and 
corners, which inflict unnecessary discomfort on the patient by 
lacerating the gum. In the ones here shown these angles are 



22 PKINCIPLES AND PEACTICE OF FILLING TEETH. 

rounded off, so as to leave a smooth back to tlie instrument, wliicli 
may be insinuated under the gum and along the root without 
serious disturbance to the patient. Fig. 12 is merely a short- 
bladed hoe excavator, while Fig. 13 is a delicate hatchet excavator, 
the uses for which will be considered later. Fig. 14 is a curved 
wide push-cut scaler for passing over the surfaces of teeth where 
the bulk of the deposit has already been removed, and scraping off 
any small particles that may have been left. Fig. 15 is a long- 
reach push-cut scaler for approaching localities in special cases 
inaccessible to the ordinary instruments. 

Technique of the Operation. 

In the examination for calculus on the teeth probably nine out 
of ten operators will instinctively place the mouth-mirror between 
the tip of the tongue and the lower incisors, and reflect the light 
upon the lingual surfaces of these teeth. It is therefore natural 
that the removal of the deposits should begin at this point, and 
there is also another minor reason why it is well to start where 
there is considerable material to be removed. It makes an instan- 
taneous impression on the mind of the patient as to the extent of 
the deposit present, and arouses an interest in the work which 
nothing else will. It is seldom that a patient realizes just how 
much calculus there is upon the teeth, due to its gradual formation 
and the fact that the tongue becomes accustomed to its presence. 
But if, on the first introduction of the scaler, several large pieces 
are flaked off and allowed to fall into the floor of the mouth, the 
patient is startled into a realization of what has been going on, and 
is impressed with the importance of proper attention to the matter 
in the future. The same impression never seems possible later on 
in the operation if the large masses are left till the last. 

For the removal of salivary calculus from the lingual surfaces 
of the lower incisors in ordinary cases the scaler illustrated in 
Fig. 6 is admirably adapted. (It need not here be urged that all 
scalers should be keenly sharp in whatever location they are used.) 
With the mouth-mirror in the left hand, and held in such a posi- 
tion that the tongue is kept well away from the lower incisors and 



DEPOSITS ON THE TEETH. 23 

the light thrown upon the deposit, the first movement of the 
operating hand should be to firmly brace the end of the third 
finger against the occlusal surfaces of the adjacent teeth in such a 
manner that the patient must at once realize that the operator has 
complete control of the instrument against slipping. This ac- 
complished, rapid Avork is possible. A push-cut should be used 
along the disto-lingual surface of the right lower lateral, and the 
deposit dislodged. Immediately this is done the point of the 
instrument should be turned rootwise of the deposit on the mesio- 
lingual surface of the same tooth, and a draw-cut given to flake it 
off along that surface. Thus with two movements, one downward 
and the other upward, the large bulk of calculus from that tooth 
has been dislodged in the most expeditious manner. The same 
plan should be followed successively with the other teeth in line 
as far as the left cuspid, when the sickle-shaped scaler should be 
exchanged for Fig. 14. With this the entire lingual surfaces of 
these teeth should be scraped to remove any small particles of 
deposit which may have been left by the other scaler, and, follow- 
ing this, attention should be given to the lingual surfaces of the 
left lower bicuspids and molars. Beginning with the mesio- 
lingual aspect of the first bicuspid, these surfaces should be fol- 
lowed in regular order to the distal surface of the left lower third 
molar, the instruments usually best adapted for this work being 
either the hoe or hatchet forms. Figs. 12 and 13. The lingual 
surfaces of all of the lower teeth to the left of the right cuspid have 
now been covered. To reach the lingual surfaces of the right 
cuspid and the teeth posterior to it the operator should step slightly 
forward and face his patient, so as to look along these teeth. Then, 
with the hatchet instrument held in the palm and the thumb 
braced against the teeth, the deposit may be lifted from the necks 
very expeditiously. 

After the lingual surfaces are attended to, the buccal and labial 
surfaces may ordinarily be reached with the hatchet instrument, 
using the pen grasp for the right side of the mouth as far forward 
as the cuspid, and then changing to the palm grasp for all the 
teeth to the left of that. These surfaces should be followed sue- 



24 PEINCIPLES AND PRACTICE OF FILLING TEETH. 

CGssively from one third molar to tlie other. As the deposit is 
being lifted from the labial aspect of the lower incisors, care 
should be taken that the pieces of calculus do not fly into the 
operator's eyes. The force is necessarily exerted directly toward 
the operator, and the particles sometimes snap off with consider- 
able momentum, so that accidents of this nature are not un- 
common. 

When large masses of calculus are found on any of these sur- 
faces, it may be removed with the push-cut instruments, Figs. 1 
or 14. In cases of great recession of the gum and extensive 
deposits along the exposed portion of the roots, particularly if the 
teeth lean in toward the tongue, so that they stand obliquely in 
the arch and are very long, the lingual surfaces can only be 
reached to good advantage with an instrument like Fig. 15. In 
using this on the lower incisors or right cuspid, bicuspid, or molars 
it will be found better to pass to the left side of the patient and 
throw the light down into this secluded locality with the mouth- 
mirror in the left hand. The right hand, grasping the scaler, may 
pass around the patient's head to the right angle of the mouth, so 
that the end of the third finger rests on the occlusal surfaces of the 
teeth in the region of the right lower cuspid or first bicuspid. 
Braced in this way, effective push-cutting may be done without 
impingement on the gum. 

When the deposits have been thoroughly removed from the 
buccal, labial, and lingual surfaces there remain only the proxi- 
mal surfaces to claim attention. For this work where there has 
been a recession of the gums, and the deposit is accordingly of a 
salivary formation, the push-cut method of removal is by far the 
more effective. The chair should be raised so as to bring the 
patient's lower teeth well opposite the operator, and a direct push- 
cut exerted from labial or buccal to lingual across the proximal 
surfaces. For this work the scaler Fig. 7 is mostly serviceable, 
though in some cases Fig. 8, having a longer reach and a more 
delicate form, is applicable. There are certain instances where 
this method of push-cutting from labial to lingual on the lower 
incisors is indicated at the very outset of the operation, before any 



DEPOSITS ON THE TEETH. 25 

attempt is made to use the scaler Fig. 6. This is where there has 
been much recession of the gums and the interproximal spaces are 
wide and filled with calculus, and the lingual aspect of the deposit 
presents a solid phalanx of incrustation, with only the merest line 
to show the demarkation between the different teeth. If a case 
of this kind is approached from the labial aspect and the push-cut 
scaler Fig. Y is forced between the teeth along the proximal sur- 
faces toward the lingual, the large masses of calculus may be 
tumbled off into the mouth with astonishing ease and rapidity. 

The operator should study the various means of attacking these 
deposits, to the end that he may approach the work in the dif- 
ferent phases of the deposit and be able to meet each case in the 
most expeditious manner. 

In removing salivary calculus from the upper teeth the operator 
may start at the buccal surface of either third molar. The work 
may be done vnth. push-cut scalers if the deposit is bulky, or with 
the hatchet and hoe forms if it consists only of a narrow ring near 
the gum. For the proximal surfaces of these teeth the hatchet 
form seems best adapted, there being less facility for employing 
the ordinary push-cut instruments than with the lower teeth. It 
is seldom that salivary calculus is found on the lingual surfaces of 
the upper teeth, but whenever it does occur it can best be removed 
with the hoe form. Fig. 12. 

Removal of Serumal Calculus. 

This operation is one really requiring the utmost delicacy of 
touch and the highest degree of digital perception. All of the 
work is done under cover of the gum, where the operator cannot 
see, and consequently the sense of feeling is the only guide. This 
sense must be highly developed if the operator expects to attain 
anything like success in this work. He must be able to distinguish 
accurately by the impressions conveyed to him through contact of 
the instrument with the root of the tooth whether he is touching 
calculus or cementum; and he must do this not by reason of the 
bulk of the deposit, but from the nature of its density. There is 
a decided difference in the character of the two substances, and 



26 PRINCIPLES AND PRACTICE OE FILLING TEETH. 

the practiced operator can make a sharp distinction between them. 
The necessity for this lies in the fact that in many instances the 
formation is limited to the thinnest possible scale along the 
side of the root, sometimes resting in a concavity, so that there 
is no appreciable elevation of the deposit over the surface of the 
root. In such cases the instrument must be gently raked over 
the surface, and the line of demarkation detected betvp-een the 
deposit and the cementum. This may be done by carefully noting 
the difference in the effect upon the blade of the instrument when 
encountering the two materials, cementum and calculus. In pass- 
ing over cementum a sharp instrument will readily peel up the 
tissue and scrape it off, much as one may scrape a bit of bone. It 
has a dead, comparatively soft consistence, so that the scaler 
"bites" into it readily. With serumal calculus the case is dif- 
ferent. The scaler encounters a hard, flint-like substance, which 
gives a decided resistance to the instrument, and which cannot be 
scraped to lessen its bulk. It must be dislodged en masse or not 
at all. By cautiously feeling along the root the expert operator 
is thus enabled to detect the slightest flake of calculus and to 
remove it. 

The instruments best adapted for this delicate kind of work are 
the hooked forms. Figs. 9, 10, and 11. They may be insinuated 
up under the gum into a pocket alongside the root, and thus scrape 
it free from deposits with a draw-cut. The straight form. Fig. 9, 
will be found serviceable for most of the work, though occasional 
cases on posterior teeth call for the curved forms, 10 and 11, 
Fig. 10 may be used on the distal surfaces of molar and bicuspid 
roots, while Fig. 11 will best reach the mesial surfaces of such 
teeth. The greatest patience and perseverance are necessary for 
the thorough removal of this thin scale-like deposit, but no opera- 
tor does his full duty to his patient when he allows it to remain.. 

There is another variety of deposit coming under the head of 
serumal which is distinct from the scale-like form, and is fre- 
quently met in cases where there is no appreciable pocliet. This 
is a narrow ring encircling the root just under the free margin of 
the gum, dark in color, dense in structure, and well defined in 



DEPOSITS OX THE TEETH. 27 

outline. The only indication of its presence is a slightly puffed 
and, congested condition of the gum lying over it, and in some 
instances even this is not very apparent until the deposit assumes 
appreciable size. It cannot be seen by the operator without press- 
ing the gum back from the neck of the tooth, but it may be felt 
with a fine explorer. It is often present on the proximal sur- 
faces without forming on the others, and it seems to work its 
greatest injury between the teeth. If allowed to go unchecked 
it results in a detachment of the gum from the root in the inter- 
proximal space, and a general impairment and puffing of the 
gum-festoons. 

The removal of this band of calculus is usually best accom- 
plished on the lower jaw by delicate push-cut scalers, and the work 
is greatly facilitated if the operator will pack the interproximal 
spaces in advance with small pellets of cotton to force back the 
gum, so as to expose the deposit. The cotton requires to be in 
only a few minutes, and on its removal the scaler must be con- 
veniently at hand in order to accomplish the work before the gum 
creeps back over the deposit. A ready method of procedure is to 
force cotton into two or three spaces and keep that number in 
advance of the operation, so that by the time each space is reached 
the gum will be well out of the way. In this manner the calculus 
can ordinarily be seen distinctly, and removed more expeditiously 
than if it were all done solely by the sense of touch. For the 
upper teeth the delicate hatchet excavator will usually be indicated 
in place of the push-cut instruments, and in some localities, par- 
ticularly along the lingual surfaces, the hoe form will be most 
effective. 

The surfaces of all roots where serumal calculus has found at- 
tachment should be very carefully scraped and left smooth, so that 
the gum may resume its normal position and tonicity. If small 
particles of the deposit are overlooked and allowed to remain 
they not only irritate the gum, but they invite the rede- 
position of fresh calculus so that the relief is only temporary. 
The gum need not be expected to become healthy where any 
appreciable particles of the deposit arc left, and in a week or two 



28 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

after the operation for removal it is frequently possible to locate 
the precise points at which flakes of calcnkis have been overlooked, 
on account of the appearance of the gums at these places. If a 
purplish or congested condition of the gum persists at certain 
points, it may be taken as an almost infallible indication that a bit 
of serumal calculus is lying under it. These facts are eloquent 
object-lessons as to the necessity for constant vigilance in keeping 
the teeth free from deposits. 

Removal of Stains from the Teeth. 

After salivary calculus has been removed with instruments, it 
will usually be found that the surfaces formerly covered by the 
deposit are left somewhat roughened and in need of polishing to 

Fig. 16. 




prevent a ready attachment of fresh calculus, while the surfaces 
■extending from the point of deposit are ordinarily more or less 
stained and unsightly. To complete the operation as it should be, 
and also to remove stains from the teeth where there has been no 
salivary calculus, it is necessary to so polish the surfaces of the 
teeth by friction that the enamel will assume a white and glisten- 
ing appearance. 

This is best accomplished by rotary appliances in the engine in 
the form of brushes, rubber cones, or moose-hide points carrying 
pulverized pumice. Probably the most effective method in ordi- 
nary cases is to use the small polishing brushes made for the pur- 
pose, Fig. 16, though there are occasionally places where the cones 
or points may reach to better advantage. The brushes should 
invariably be of the stiffer variety, on account of the tendency to 
soften from the moisture after a few revolutions on the tooth. If 
the brush becomes soft it is useless. 



DEPOSITS ON THE TEETH. 



29 



The manner of using the brush is to place its end against the 
surface to be polished, and as the engine revolves to cause gentle 
pressure. The degree of pressure will determine the area of 
enamel to be covered by the brush from the spreading of the 
bristles, Fig. 16, and in this way the brush may be made to con- 
form accurately to the curvature of the gum, and thus polish the 
enamel close to the gingival line without lacerating the gum or 
irritating it. All of the exposed surfaces of the teeth should be 
included in the polishing till the last vestige of stain is removed, 
except in those cases where the tooth-tissue itself is discolored from 
tobacco or other causes. This, of course, cannot be polished off, 
though even a tooth in this condition should be made as smooth on 
the surface as possible by friction of the brush. 

In moistening the pumice for the removal of stains it is well to 
use some other liquid than water. Miller found that the peroxide 
of hydrogen had a solvent effect on green stain, and it is an 
admirable cleansing agent in a general way. While the main 
reliance in the removal of these stains should be the mechanical 
friction of the pumice, yet there would seem to be no objection to 
employing adjuncts in the form of liquids having an antiseptic or 
disinfectant, as well as a solvent, action such as this. In cases of 
highly congested gums, where the slightest contact of the brush 
causes profuse bleeding, it may be well to use with the pumice 
some one of the astringent mouth-washes on the market whose 
formulae are published and known to the operator. It is also a 
relief to the patient after a sitting for the removal of calculus, 
where there has necessarily been considerable wounding of the 
gums, to add some of this wash to the water used for rinsing the 
mouth. In every case Avhere pumice has been employed the teeth 
and gums should be thoroughly syringed with tepid solutions to 
remove as perfectly as possible all traces of the pumice, which is 
insoluble in the mouth, and which should not be left lodging in any 
quantity around the gum-margins. 

Two items bearing on the hygiene of this operation must be 
mentioned; not because they are not patent to every conscientious 
and observant operator, but because there seems to be much laxity 



30 PEINCIPLES AND PEACTICE OF FILLING TEETH. 

in these minor details on the part of some in the profession. ISTo 
polishing brush should ever be used under any possible circum- 
stance in more than one mouth. They are made in such quanti- 
ties by the manufacturers, and are so inexpensive, that there is no 
manner of excuse for so gross a violation of personal and profes- 
sional refinement. Outside of the question of conveying infec- 
tion, the idea must be sufficiently revolting to make more than a 
mere mention of it unnecessary. The moment a set of teeth is 
polished the brush used should at once be discarded, and a fresh 
one placed in the mandrel, which itself should be cleaned each 
time it is used. The other item relates to mixing the pumice. 
The same mix should not be made to do service for more than one 
individual. A convenient quantity should be prepared in a small 
glass or porcelain dish for each patient, and the dish thoroughly 
cleaned after using. These simple precautions are not only de- 
manded on the basis of professional integrity, but they are really 
remunerative in the way of inviting patronage of the most desir- 
able kind. Patients are more observant of these matters than is 
generally supposed, and they are usually appreciative of every 
effort which insures to them cleanliness and protection. 

Instructions to Patients as to the Care of the Teeth. 

The dentist has done much less than his whole duty if he con- 
tents himself with the mere performance of the operation of clean- 
ing the teeth, and fails to so instruct his patient that they may 
thereafter be kept clean. Comparatively few individuals really 
know hoAv best to care for the teeth, and it should be the office of 
the dentist to so educate those coming under his charge that the 
result will be a more general enlightenment on this important sub- 
ject. An opportune moment for making an appreciable impres- 
sion is just at the conclusion of a sitting for the removal of calculus 
and stain, when the patient's mind will most likely be in a recep- 
tive mood on the subject. 

The technique of brushing the teeth should be explained so 
that the patient may learn how to reach all of the surfaces with 
the brush, and to impart the requisite friction to the gums and 



DEPOSITS ON THE TEETH. 31 

teeth -without doing injury. The ill-advised cross-brushing of 
teeth with gritty powders has undoubtedly done much harm in 
forcing the gum away from the necks of the teeth, so as to admit 
of a groove being cut by the brush just rootwise of the enamel. 
Cross-brushing is not entirely unavoidable in a thorough cleansing 
of the teeth, nor is it at all injurious if used with judgment, but 
the patient should be taught the danger of an indiscriminate 
sawing against the necks of the teeth with a stiff brush loaded 
with a gritty powder or paste. The general plan of brushing the 
teeth should be to produce a sort of rotary movement with the 
brush, so as to bring the bristles against the lower gums and teeth 
on the upward motion and against the upper ones on the down- 
ward motion. This cannot be done with anything like precision 
on all of the teeth, but it should be the general aim vnth. the idea 
ever in mind that the gums require friction as well as the teeth, 
and that they must be brushed against the necks of the teeth 
instead of away from them. In cases where the patient complains 
that the gums are too sensitive to admit of proper brushing of the 
teeth, they should be subjected to a thorough system of massage 
with the fingers three or four times a day till they become suffi- 
ciently hard to comfortably tolerate any ordinary brushing. 

As to the frequency with which teeth must be brushed by the 
patient to keep them well cleaned, no definite rule can be given 
on account of the variation in the different mouths. In one indi- 
vidual the teeth may be kept in admirable condition with one-half 
the care that would be necessary for another, and even in the same 
individual there is considerable variation at different periods in the 
tendency to the accumulation of deposits. Patients must there- 
fore be requested to study the matter on their own behalf till they 
learn with some degree of accuracy just how much care is neces- 
sary to keep the teeth bright and clean. 

The use of floss for passing between the teeth and removing 
any particles which may be found lodging where the brush will 
not reach is an admirable practice, provided the patient will use it 
judiciously and without working injury to the gum. The great 
danger, as used by most individuals, lies in the fact that in passing 



32 PKINCIPLES AND PRACTICE OF FILLING TEETH. 

it between the teeth it is inclined to snap as it passes the contact, 
points and come down forcibly upon the festoon of gum. This 
may in time injure the gum and force it back in the interproxi- 
mal space, leaving the space imperfectly filled with tissue. When- 
ever floss is used it should be most carefully guarded as it is pass- 
ing the contact points and prevented from impinging on the gum, 
and unless the patient can gain control of it in this way it had 
better not be used. 

One feature in the care of the teeth by the patient must not be 
overlooked. This relates to the use of toothpicks, which, if 
properly employed and of suitable form, may be used to advantage 
for the dislodgment of certain kinds of food-material from between 
the teeth, but which if used as they too commonly are may result 
in great injury to the gums. The large blunt wooden toothpicks 
so extensively provided for the patrons of public eating-houses are 
especially calculated to work irreparable injury if persisted in. 
Outside of the rough nature of the wood and the sharp corners and 
blunt ends, all of which tend to irritate the gums, the very bulk 
of the pick is such as to finally force all of the gum out of the 
interproximal space and furnish a receptacle between the teeth 
for the constant collection of food. Dentists should invariably 
discourage the use of such destructive agents as these. Whenever 
a toothpick is indicated at all, it should be of the very thinnest, 
smoothest, and most fiexible nature. Probably the best toothpick 
is the quill, which can be scraped with a knife to any degree of 
fineness and pliability. The constant habit of picking the teeth, 
as a habit, should be discouraged, and the custom limited to the 
mere removal of particles of food which may find lodgment, 
between the teeth. 



DENTAL CAKIES. 33 

CHAPTERII. 

DENTAL CARIES. 

It is scarcely within the province of this work to enter minutely 
into the etiology of dental caries, and yet a few observations bear- 
ing on the subject from an operative point of view would seem to 
be eminently in order. Dental caries has been accounted one of 
the most prevalent of all human diseases, and one of the most per- 
sistent through life, in view of which it would appear on the face 
of it a very discouraging task to attempt to combat this affection. 
In fact, there are many men in the profession who apparently give 
themselves over very easily to this idea, and consign the natural 
teeth to the grasp of the forceps with a resignation which borders 
closely on an assumption of the inevitable. This ready yielding 
on their part has its influence on the patient, and an unfortunate 
impression is thus allowed to go out to the effect that in many cases 
it is quite impossible to save the teeth, and therefore waste energy 
to make the attempt. This teaching is wrong in the highest 
degree, and the profession has much to answer for if it fails to 
inform itself in the most intimate manner on the true relation of 
this disease to the human economy, and on the best means of 
securing its control. 

A close study of the manifestations of dental caries will reveal 
the fact that while it may be considered a very persistent disease, 
it is seldom the case that it is continuously so either in relation to 
its initial appearance or the degree of its severity. Some of the 
most discouraging cases that come under the attention of the 
practitioner will be found, if carefully studied, to experience 
periods of immunity from attack, during which the process of decay 
seems for the time suspended. In fact, it is the exception, rather 
than the rule, for teeth to go progressively to destruction from 
caries one after the other till every tooth is lost without intervals 
of practical cessation of activity on the part of the micro-organisms 
which bring about decay, even where no attempt is made to combat 

3 



34 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

the disease. Cases are frequently noted where a number of teeth 
in a mouth have been lost through caries while the remaining teeth 
present themselves years afterward practically free from caries, 
the disease seemingly becoming limited with the loss of the teeth 
that are missing. It might be thought in such cases that there 
was something in the structure of the remaining teeth which ac- 
counted for their escape were it not for the fact that these same 
teeth may at a subsequent period, without any appreciable provoca- 
tion, take on an active attack of caries and require the closest 
attention to save them. 

In a broad view of the whole question of the susceptibility to or 
immunity from caries, it seems to resolve itself down to the fact 
that in some mouths the conditions are such that the micro-organ- 
ism of caries cannot work effectively upon the teeth, while in 
others they are favorable to its most active influence, and that in 
the same mouth there are periods when the conditions favor the 
work of the micro-organism, and others when they interfere with 
its action. Just what these conditions are the profession at present 
do not seem to be able to determine, but the investigations of Dr. 
J. Leon Williams, and more recently of Dr. Michaels, of Paris, 
would appear to promise an encouraging step toward the solution 
of the problem. Professor W. D. Miller had demonstrated some 
years ago that caries was brought about by the action of an acid 
produced as the result of micro-organic growth in the mouth, and 
Dr. G. y. Black called attention to the fact that this acid must 
be formed and allowed to act immediately at the point where the 
decay was to begin. (In fact, Kobertson, in 1828, indicated that 
the carious process was the result of some influence acting directly 
on the enamel at certain points where the cavities were to occur, 
his idea being that this influence was due to "decomposition.") 
It was therefore seen that the old and somewhat prevalent idea 
that the reaction of the saliva had something to do with the 
progress of caries must be abandoned, so far, at least, as any direct 
action on the tooth-tissue was concerned. Saliva in the mouth 
cannot become sufficiently acid to penetrate the teeth in the way 
we flnd decay manifest in most cases. If it were so sharply acid 



DENTAL CARIES. 35 

the soft tissues could not tolerate it, and, besides, if it was the 
saliva which did the work we should find the entire exposed sur- 
faces of the teeth melted down instead of being penetrated at cer- 
tain points. It remained to be determined how any requisite 
number of micro-organisms could remain stationary on certain 
unsheltered surfaces of the teeth where decay was seen to occur 
for a sufficient time to form their acid and dissolve the enamel, 
mthout being washed away by the fluids of the mouth. 

It is found in the cultivation of micro-organisms that there are 
certain fonns which in the progress of their development form a 
substance allied in physical appearance to gelatin, and are there- 
fore called gelatin-forming micro-organisms. It is to this class 
that the micro-organisms of caries belong, and, in pursuance of 
their function, they produce on the surface of the tooth a gelatin- 
ous film, under cover of which they are enabled to work their de- 
structive processes undisturbed. This film is sufficiently adherent 
to the tooth to withstand the ordinary rinsing of fluids in the mouth, 
and thus we see decay taking place in positions where the micro- 
organism itself would be washed away if left unprotected. But 
the film may be broken up and detached by any appreciable 
amount of friction, such, for instance, as the friction of food in 
mastication where that process is exercised to its fullest functional 
activity. Accordingly, we may look for the greatest ravages of 
decay in surfaces of the teeth not subject to the friction of food, 
as the proximal surfaces, or in sheltered localities formed by de- 
velopmental defects, as in the fissures or pits where the micro- 
organisms may work unmolested, and this phenomenon is amply 
demonstrated in clinical observation. 

The legitimate office of the tooth-brush, the dental floss, or the 
toothpick may be more intelligently comprolionded when the 
character and significance of this gelatinous film is understood. 
If that fihn can be kept from the teeth it would seem that we have 
small need for worry over the problem of controlling dental caries, 
and in this connection our advice to patients as to the proper time 
to brush the teeth should be governed largely by a recognition of 
the facility with which this film may form under favorable con- 



36 PEINCIPLES AND PRACTICE OF FILLING TEETH. 

ditions. If we find a mouth where decay is progressing rapidly, 
showing active work on the part of the micro-organisms, we should 
advise frequent attention to the teeth, so as to interfere as largely 
as possible with the formation of these films. Brushing the teeth 
three times a day under these conditions will not be too much, but 
the time of all others when it would seem necessary to go over 
every surface carefully with brush, pick, or floss is just before re- 
tiring, when the fluids of the mouth are to remain quiet for the 
greatest length of time in the twenty-four hours, and the micro- 
organisms are given the best opportunity for work. 

Dr. Williams's notable achievement in clearing up this subject 
of the modus operandi of dental decay relates to the fact that he 
succeeded in grinding sections of the teeth sufficiently thin for 
microscopical examination, and at the same time retaining in place 
this gelatinous film with its nest of micro-organisms thereby glued 
to the enamel, and showing plainly the action of the acid upon the 
tooth-tissue. This was the missing link which changed conjec- 
ture into certainty, and developed one of the most significant fac- 
tors in the institution of dental caries. It showed the importance 
of this film in locating the beginnings of decay as we usually find 
it, and yet from this it must not be inferred that the fact is fully 
established that it is impossible to have decay without the films. 
Any agency which will hold the micro-organisms in situ against 
the enamel for a sufficient time to form their acid undisturbed 
will bring about the result, but in the actual process in the mouth 
it seems apparent that the film is a conspicuous factor in the first 
attack upon the enamel, and that anything which tends to prevent 
its formation will to that extent act as a prophylactic. It is true 
that Dr. Miller in an article in the Dental Cosmos, May, 1902, 
throws some doubt on the significance of the film in its relation 
to dental caries, and yet he acknowledges that because decay may 
sometimes be found without the film in place it is no proof that 
the film may not have been there at one time in the early stages 
of the disease. This subject needs further study, not only in 
laboratory investigation, but in its manifestations in the mouth. 

As has been intimated, cleanliness of the teeth may be con- 



DENTAL CARIES. 37 

sidered au important adjunct in checking the inroads of the micro- 
organisms, but unless it is faithfully pursued, and the cleansing is 
of sufficient frequency, it will not be found wholly effective in pre- 
venting caries in mouths where the tendency to its development is 
favorable. It is a question of hours instead of days when these 
micro-organisms can form gelatin and produce acid, and a mouth 
may be cleansed as perfectly as possible once in twenty-four hours 
and yet give the micro-organisms ample time to act in the inter- 
vals, provided the conditions are suitable to their progress. 

This question of condition is the keynote of immunity or sus- 
ceptibility, and it is to the study of the fluids of the mouth that 
Dr. Michaels has been devoting his energy, with a view of de- 
termining the particular elements in the saliva which may be 
considered pathognomonic of certain diseases. It is his aim to 
study the characteristics of different salivas so that he may 
eventually be able, by an examination of the saliva of an in- 
dividual, to determine whether that individual is susceptible to 
dental caries or immune from it. It is along this line that future 
investigation must advance before we are able to fully solve all of 
the problems connected with the etiology of this disease. 

It was formerly the prevalent idea in the profession that the 
structure of the teeth had much to do with the liability to decay; 
that teeth which were found to be extensively attacked must be 
considered of poor structure, while those practically free from 
caries were accordingly accounted as being of good structure. The 
investigations of Dr. Black into the physical character of the teeth 
proved that this position was untenable ; that there was really much 
less variation in the structure of the teeth than had been supposed, 
and that what little difference did exist seemed to have almost no 
relation to the liability to decay. It simply resolved itself down to 
a question of environment. If teeth decayed rapidly in a mouth 
it was because the conditions in that mouth were favorable to the 
agencies which bring about decay, and not because the teeth were 
necessarily of poor structure. 

That conditions exist in the mouth which influence this matter 
for good or ill is clearly evident from a clinical study of cases. 



;}S nuNoiri.Ks and rK.vt^rioE of filling teeth. 

AVo lind tli:il \hovo is in tlio snino individual a great variation at 
(lilTtMHMil p(M'i(Hls in I ho UmuUmu'v \o caries, and since we have 
loarurd that {he tooth (issm^ is not S(^ lluotiiatinj;' in its character, 
and does not grow hard and soft so readily as Avas fornierlv snp- 
pt^sod. >V(^ must look to changes in the conditions surrounding the 
iocih (o acconnt l\>r the \arving manifestations of the disease. 

A cU^^e study of cases in practice will reveal some rather 
marked instances of periodical snsce}>(ibility and immunity, and 
the history of these cases will often prove not only of the greatest 
valm\ hut also a som-ce of the ntn\ost satisfaction and encourage- 
ment. The recital at this point of a single case from practice may 
serve to indicate the common run of such clinical histories where 
the disease is followed up vigorously by the dentist. This case 
sccnu\l a desperate one. a case in which, under ordinary circum- 
stances, many of the teeth would probably have been lost if any 
half-hearted methods of treatment had been employed. And yet 
the tlual outcome was such as may be contldontly expected in nine 
I'ases out of ten where the dentist is in earnest with his work and 
has an intelligent conception of the possibilities of an approaching 
immunity. 

The patient was a girl of eight or nine when brought to the 
dentist by her parents, and the first permanent molars were already 
atVected. From this time forward during the next six or seven years 
the activity of the carious process in that month was appalling. 
TeetJi would decay on their journey through the gums in eruption; 
recurrences of caries around tillings would take place with discour- 
aging frequency, and new cavities would spring up seemingly 
almost in a night. The dentist did the best he could, which he 
freely acknowledges was not very good, owing to the liypersensi- 
tivene*vs of the dentine wherever decay occurred. But an honest 
effort was made to fight back the intruder, and to encourage the 
patient to persevere in the face of the most disheartening condi- 
tions. Glold was out of the question, and resort was accordingly 
liad to anialganu the cements, and gutta-percha. Even then the 
cavities were often not well prepared, through fear that radical 
methods of treatment would prove too great a tax on the patient 



I>hN'JAL CAJUKH, 89 

and t.if) tlu; Iciljinoc in tlin wrong dirfir-.tifui, ho fluil, h[io vvoulrj give 
up the work in flasfjjiir arifl \cX Ifio friclji go. At t,ifnf;H <Jijring 
those trying yoars if, Hf-f;irif;(i alrnoHl, ;i lioprKiHK fiJiHf;, Jirxl yr;f, liio 
Bacrifico of lo.sing a net of t,<;r;f,h wliif;li in af)pf;ar!irif;o w(;rf5 nially 
bcantifnl wan too groat to Ijc tJionght of. 'I'lir; patient waH in- 
structed to report for examination every flirce months. Homo- 
times she would appear hf-foif. the allotted time with the Htereo- 
typed remark, "Dor-.tor, I am afraid tliere are otfif:r eavitiriH eom- 
ing," And thr;y nniially were eorning. It grew to f>r; Hornritfiing 
of a dread to have thin patient'.s name announced, and yet Khe w&n 
never met with anything hut the most eneouraging demeanor, and 
the idea was eouHtantly neliooled into fier tliat thoHe teeth mnnt ho 
saved at any cost. 

This kind of warfare wa« kept iif» till nfir; wan nixteen or mvan- 
tf«;n, wlien a f>eriod (>f a year elaf>H^;d without fier reporting at the 
office, and the natural inference wa« that «he had finally yielded U> 
what Hf'jiuu-A the inevitafde and waH allowing the teeth U> go by 
default. Biit one day nhe came again with a r('j\\U'Mi to have her 
teeth examined, Haying that Hhe had experienced no trouble with 
them in the interval, but thought they mu«t by thin time need 
attention. 'J'he first glance at the teeth revealed a condition 
entirely different from anything that had ever been not-ed in that 
mouth before, and the dentint reabV/jd iuHtantly that the battle 
had at last bf;en won. 'J'he HwriacA-M of the t/;eth w-.ro, cU-Zdn and 
bright, and the gum.H hard and normn]. When quf^tioned hh ij> 
whether »he had given the te^;th particular attention since her 
last visit to the offir;^;, the patient «aid that she wan not cons<;ioiw 
of having done more than the ordinary. 

Sinee then, now more than Heven years, there has \>f'j:u nlffumt no 
neceH?.ity for dental s^irvice in that mouth, exrjf;pt to rcfAnfJi 'with 
gold the worn-out cement and gutta-percha fillings one by one an 
they f'diU-A. 'Jo-day the young lady ha« her full complement of 
natural teeth, without even the iK-z-jmity of having had any of 
thern crowned. The \)mU;rior te^jth are m'^^st inarti«tically jf&U'.hfA 
and plastered with amalgam, but from an anterior view i\m youuf^ 



40 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

lady woTild be credited by the average observer with having an 
exceptionally good and an exceptionally beautiful set of teeth. 

Such a result as this — and the case here recorded is by no means 
an isolated one — should prove of the greatest possible encourage- 
ment to both operator and patient, and should stimulate the practi- 
tioner to take vigorously in hand even the most unpromising case 
and fight back the disease, no matter how active its ravages appear 
to be. Immunity does not always develop so suddenly or so com- 
pletely as in this instance; in fact, there are some patients who 
never seem to become immune, but in the vast majority of indi- 
viduals we may confidently look for a very appreciable change in 
the liability to decay as age advances from childhood to middle 
life, provided we take stringent measures to control the difficulty. 
It would seem from clinical observation that the period of 
immunity is hastened by an active campaign against the develop- 
ment of caries, whereby the occurrence of large cavities is avoided 
and the teeth are kept comfortable for the maintenance of a full 
functional activity. ISTeglected cavities in teeth invite decay in 
adjacent teeth, and wherever the function of mastication is inter- 
fered with through sensitiveness the teeth in that locality are 
deprived of the adequate friction to keep them free from adhesive 
materials of a character calculated to bring about decay. The 
highest degree of health in the mouth, as elsewhere, is to be 
obtained only by the requisite exercise of all the functions, and 
this cannot ensue where the teeth are sensitive from decay or 
where they are not adequately used in mastication. A close study 
should be made to determine whether or not the patient masticates 
fully, and if it is found that this function is not properly per- 
formed the patient should be vigorously schooled into an observ- 
ance of its necessity. 

It is of the very greatest importance, if immunity is to be estab- 
lished early in life, that the most strenuous efforts be made to 
check the disease in its incipiency, and to keep a watchful eye 
over the general condition of the mouth to see that the functions 
are normally active. ISTor must it be assumed that even where an 
apparent immunity has been once established the case will invari- 



DENTAL CAKIES. 41 

ably remain permanently immune. Relapses seem as likely to 
occur here as in other diseases, thongh they are usually manifested 
in a different manner, and they do not necessarily follow the 
initial attack for some years. In the case just recorded the proba- 
bility is that, even after this long period of practical immunity, if 
the young lady gets married and is called upon to pass through all 
the concomitant vicissitudes of motherhood, those treacherous 
little micro-organic dogs of war will be turned loose upon her teeth 
once more, and there will be another contest for supremacy. 
Decay will commence again in a manner to discourage any pract-- 
tioner who has not a well-defined idea as to the usual manifesta- 
tions of periodical susceptibility and immunity, but to one who 
is accustomed to watching these cases there can be only one mind 
as to the final outcome, provided the proper coiu'se is pursued. If 
the case is met in a vigorous manner, and the teeth kept comforta- 
ble by checking the decay in its earliest stages, the attack will soon 
pass by and the teeth be saved. In some of these relapses, when 
the circumstances are such that the patient is unable to apply to 
the dentist with sufficient frequency, a pulp is occasionally lost and 
a tooth sometimes breaks down to the degree of requiring a crown, 
but this is usually the extent of the disaster, and the mouth is still 
maintained in full functional usefulness. 

As has been intimated, it is the rarest thing to find a case where 
the carious process is uniformly and progressively active through 
life if anything like a reasonable attempt is made to check it. 
There are, of course, many cases where the teeth are lost one after 
another till all are gone, even at an early age of the patient, but 
these are usually cases where no adequate attempt has been made 
to check the disease, and where the carious process has had the 
most favorable opportunity to advance. 

In the light of what we now know, it may be laid down as a 
conservative statement to say that with proper attention the teeth 
of most individuals may be saved through life, so far as decay is 
concerned, and it is confidently believed that an intelligent concep- 
tion on the part of the profession of the phenomena presented by 
immunity and susceptibility will add materially to the possibility 



42 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

of sucIl a consummation. If the operator's attention is constantly 
directed to the conditions surrounding the teeth, rather than fall- 
ing back on the old fallacy that the tendency to decay is influenced 
by changes in the structure of the teeth, and thus entirely out of 
his reach, it will place him in a more enlightened relation to the 
matter, and he will be better equipped to meet the emergency and 
overcome it. That there is a difference in the density of teeth need 
not be argued, and that there is a wide variation in the behavior of 
teeth under the action of cutting instruments no man of long 
clinical experience will attempt to deny. Some teeth may be cut 
and chiseled away very readily, while others appear to cut like 
flint, and will dull the sharpest and hardest instrument; but a 
close observation of these cases would seem to indicate that the 
difference in resisting power to instruments is confined largely to 
the enamel, and that this difference is due more to the variation in 
the arrangement of the enamel-rods than to variations in density. 
In some teeth the rods stand straight, regular, and parallel; in 
others they are wavy and exceedingly irregular in their course. 
It is the difference between straight-grained maple and bird's-eye 
maple. The axe will readily split straight-grained maple, while 
bird's-eye maple is stoutly resistant. It is practically the same 
with the different kinds of enamel. But that there is really little 
variation in the liability to decay of the different classes of tooth- 
tissue Dr. Black's investigations proved most conclusively. The 
hardest tooth that was ever developed, if placed in a mouth where 
the micro-organisms are permitted to form their gelatinous masses 
and produce their characteristic acid, will promptly be attacked 
by caries, while a tooth seemingly friable in structure will remain 
free from caries in a mouth where the conditions are unfavorable 
to such action. It thus seems to be wholly a question of environ- 
ment, though it is not here intended to intimate that the denser 
tooth will break down as rapidly under the carious process when it 
has once started as will the one of less resisting structure. 

That well-formed enamel is capable of being attacked is amply 
demonstrated by the location of many of the cavities we find in the 
mouth. The proximal surfaces of the teeth are probably attacked 



DENTAL CARIES. 43 

as often as any other, and at this point we do not ordinarily 
look for defects in the tooth-structnre. There are no pits or fis- 
sures, and the enamel is laid on as perfectly as at other surfaces 
where decay seldom occurs. The reason we find cavities on the 
proximal surfaces is because of the environment, the position 
being sheltered and free from the friction which interferes with 
the micro-organisms on exposed surfaces. Then, again, we learn 
many an instructive lesson in the examination of developmental 
defects in tooth-tissue. We ordinarily look for cavities at points 
where the enamel has failed in continuity of structure, leaving 
pits or fissures, and in a mouth subject to caries we usually find 
initial decay at these points. But, on the other hand, we fre- 
quently see cases where, on account of immunity, the teeth go for 
a lifetime containing deep fissures entirely through the enamel 
without decay occurring in any of them. These are phenomena 
which should command the closest attention of the profession, to 
the end that we become familiar with all of the manifestations of 
dental decay and have an intelligent conception of its true nature. 
If it be finally proved beyond doubt, as would at present seem 
to be the case, that the question of condition is the chief factor in 
this disease, then it devolves upon us to know what this condition 
is, and to treat cases scientifically to control condition. As has 
already been intimated, we at present know very little about this 
subject of condition. We cannot tell what particular elements 
there are in the fluids of a certain mouth tending to favor the 
formation of these micro-organic films, which seem to be the main 
instrumentality of the destructive process, nor do we know what 
constitutes a condition unfavorable to them. We are not even 
clear in our clinical observations as to surface indications which 
may lead us to judge whether a mouth is susceptible or immune, 
except as we see cavities or do not see them. And yet, even with 
our present knowledge, it should not be necessary, if we are truly 
observant, for us to see actual caries in order to know that a mouth 
is susceptible. There are unmistakable evidences present in some 
mouths which indicate the activity of the carious process to one 
who has closely studied the matter, and yet to attempt to describe 



44 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

these indications so that thej will be intelligible to others seems 
not to be easy of accomplishment. They relate rather to an 
intuitive perception of general conditions on the part of the 
observer than to any definite landmarks in the month that may 
be described. 

It is with this limitation clearly in mind that a few hints are 
herein offered for observation, with the suggestion that each practi- 
tioner take up the study of this matter in his own experience till 
he secures an intelligent basis for judgment. 

A mouth that is acutely susceptible will ordinarily present an 
unkempt appearance; not necessarily resulting in the presence of 
salivary calculus, but apparently indicating that the teeth are not 
well cared for. Accumulations of a soft nature may be scraped 
from the surfaces, as if the patient had just arisen from a meal of 
pasty materials and had not even rinsed the mouth. The fluids 
around the teeth seem to contain much thick mucus, which ren- 
ders the semi-solid substances adhesive to the surfaces of the 
enamel, though the saliva on entering the mouth at the orifices of 
the ducts may appear of normal fluidity. If such a patient is 
handed a glass of water and asked to rinse the mouth thoroughly, 
it will be found that after the attempt is made the teeth are left 
with these glutinous accretions still clinging to them. ISTothing 
but a very vigorous rubbing will leave the teeth reasonably smooth, 
and even after the most thorough cleansing it is only a matter of 
a few hours when they are found coated again. The first impres- 
sion on looking into such a mouth is that the patient ignores dental 
hygiene altogether, and yet some of these cases are at least as well 
cared for as the average. It simply seems an almost impossible 
task to keep the teeth free from accumulations. If a thin, flexible 
scaler be passed along the sheltered surfaces of the teeth it will 
almost invariably peel up a film of gelatinous material, and even 
the occlusal surfaces of such teeth are never found as highly 
polished as ordinarily. The teeth seem to invite the adhesion of 
materials as if the enamel were roughened, and in connection with 
this the gums are usually found more or less hypertrophied, so that 
the festoons creep up over the teeth more prominently than normal 



DENTAL CARIES. 



45 



and bleed on the slightest touch. This is frequently noted in 
such cases, even where there are no calcareous deposits to account 
for it. A mouth in this condition should be watched very closely 
with the expectancy of caries if the condition persists for any time. 

The change from this to a state of immunity is usually marked 
by a general clearing up of the fluids of the mouth, with decreased 
viscidity and tenacity. The mouth can be rinsed tolerably clean 
without the use of the brush, and there is an appearance of cleanli- 
ness, as if better care were taken of the teeth even in cases where 
no change has been made in the patient's habits in this regard. 
There is little tendency for the accumulation of foreign material 
about the teeth, and the impression on the observer is that there 
seems to be some kind of solvent present in the mouth which keeps 
the fluids clear and prevents the formation of the glutinous masses 
seen during the susceptible period. Coincident with this the gums 
shrink to their normal form and become firm and pink, and do not 
readily bleed on pressure. 

When the operator observes these changes going on in a mouth 
that has been causing him imlimited anxiety, he may feel much 
the same sense of elation which comes over a physician when he 
finds a patient who has been suffering from a high and stubborn 
fever suddenly bursting out into a generous perspiration. The 
tension is relieved, and for the time at least the dogs of war are 
chained, so that both operator and patient may have a chance to 

breathe. 

It may be stated in passing that clinical observation would 
seem to prove that the condition of immunity may be brought 
about earlier by a rigorous campaign on the part of the dentist 
and the patient"'in the way of perfect cleanliness of the teeth, and 
the performance of all necessary operations in the inception of 
the disease. Neglected teeth seem to invite and continue condi- 
tions of susceptibility. The dentist should see the case at regular 
intervals sufficiently frequent to keep a close supervision of the 
general conditions of the mouth. If the teeth become stained or 
covered with a viscid material despite the efforts of the patient, 
they should be subjected to a thorough polishing till they are 



46 PEINCIPLES AND PKACTICE OF FILLING TEETH. 

made white and glistening, and if the smallest cavity presents it 
should be filled at once before it contaminates a contiguous sur- 
face. In other words, the environment of the teeth should be 
carefully looked after, and the decay kept down to the smallest 
possible limit. 

The practical lesson of this whole study of susceptibility and 
immunity resolves itself into the fact that an operator is never 
justified in allowing even the worst case of dental caries to go by 
default. He should institute the most vigorous proceedings 
against the enemy, with the idea ever in mind that sooner or later 
the kindly ofiices of beneficent nature will intercede and help him 
win the battle. It is his duty in the darkest hours of these trying 
cases to explain to the patient as clearly as he may the theory of 
immunity, and offer such encouragement as an understanding of 
this phenomenon will suggest. By so doing he will often carry 
the patient through a disheartening experience, which otherwise 
would prove sufficient to cause a total neglect and loss of the teeth. 



CHAPTEK III. 

EXAMINATION OF THE TEETH FOR CAEIES. 

When a patient selects a dentist and places the teeth in his 
charge, it is the dentist's duty to make a careful examination of the 
teeth at intervals sufficiently frequent to enable him to keep per- 
fect control of them and prevent the possibility of caries even 
approaching the pulp, much less causing the loss of a tooth. There 
should be a definite understanding with each new patron with 
regard to the mutual responsibility existing between operator and 
patient, the former assuming the obligation of saving the teeth 
and keeping them in a condition of functional utility, barring 
accidents or unforeseen complications, provided the latter will 
faithfully report for examination at stated times to be suggested 



EXAMINATION OF THE TEETH FOR CARIES. 47 

bv the dentist. A clear understanding of this nature will not 
only stimulate the practitioner to his best endeavor, but will place 
the patient in such a relation to the matter as to lead to increased 
respect and appreciation of dental service. It will also establish 
a professional and personal sentiment between the two which will 
tend finally to a series of friendships in the conduct of a practice 
calculated to prove one of the most pleasant features of profes- 
sional life. 

As to the frequency with which patients shall be instructed to 
apply for examination, the dentist must judge on the basis of a 
study of each case in its relation to the evident tendency or other- 
wise to decay in that mouth. In some particular cases where 
the carious process seems acutely active, the teeth should be seen 
as often as every second month, while in others they may safely 
go six months. But in no case where decay has once shown itself 
should the patient fail to apply at least twice a year for examina- 
tion, and in the mean time should report immediately on the ap- 
pearance of any suspicious sensitiveness in the teeth. With 
patients who are inclined to neglect or forget these examinations 
the dentist should have an understanding whereby he shall notify 
them at regular intervals to appear for inspection. Appreciative 
patients take very kindly to the idea of these regular notices when 
they understand the motive. 

All operative procedures upon the teeth should be pursued in a 
systematic and orderly sequence, even one apparently so simple as 
the examination for caries. When it is considered that each tooth 
has five surfaces, any one of which may be decayed, it will be 
seen that to properly examine an entire set of teeth involves more 
than a casual glance into the mouth, such as is often made to pass 
muster for an examination. An operator owes it to his patient 
not to overlook the slightest defect, particularly in a mouth where 
caries is prevalent, and to this end every surface should he brought 
under critical inspection. To accomplish this at the expenditure 
of the least time the operator should have some definite starting 
point in the mouth, and proceed from this in regular order till the 
entire set of teeth has been covered. A convenient place to begin 



48 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

is the left lower third molar, and from this to the next tooth in 
line till the right lower third molar is reached, when the mirror 
may be turned to the right upper third molar, and all the upper 
teeth examined, ending with the left upper third molar. In this 
way no tooth need be missed, and the least possible time is con- 
sumed in the examination. 



Appliances for Examining the Teeth. 

These should consist of a mouth-mirror, an exploring instru- 
ment, and some unwaxed floss silk. The mouth-mirror is an 
appliance which has the widest possible range of usefulness in 
operative dentistry. It begins ^vith the examination of the teeth, 
and ends only with a final inspection of the completed operation. 
The dentist should early acquire the closest familiarity with this 
appliance, so that it becomes second nature with him to constantly 
liold it in his left hand while operating. By its use he is able to 
discover defects in the teeth which his unaided eye would never 
reveal, and when he has attained a thorough mastery of it he can 
perform many operations through the agency of the image pre- 
sented in the glass without the necessity of stooping over to look 
directly into the mouth. In any operation on the molars or bi- 
cuspids, even where direct vision is possible, the work is greatly 
facilitated by reflecting the light fully upon the operation with the 
mirror. 

For examining the teeth this reflected light is very valuable, in 
the evidence it often gives of caries on the proximal surfaces 
where the probe fails to find any defect. Sometimes decay occurs 
so near the contact point that the exploring instrument cannot 
enter it, but by throwing the light upon the teeth the enamel will 
usually show a different color from normal tooth-tissue. This 
relates to a dead white appearance which is distinctive in character, 
and readily recognized by an experienced operator. When this 
appearance is noted, and there seems no possibility of gaining 
entrance to the cavity with the finest probe, the question of 
whether there is decay or not may often puzzle the beginner. It 



EXCLUSIOJT OF MOISTUKE DURING OPERATIONS. 49 

is here that the floss silk is especially useful. If drawn between 
the proximal surfaces of the teeth where caries is present it will 
usually drag and fray against the rough margins of the cavity, 
instead of passing the contact points with a snap, as is the case 
Avliere the teeth are nonnal. In some instances the floss will 
be severed completely, and when such is the case there can l)e 
no longer any doubt about the presence of a cavity. 

The exploring instrument is especially useful for investigating 
the fissures and pits of the occlusal surfaces, and for probing 
around the teeth generally wherever the light from the glass 
cannot penetrate. It should be very fine and sharp at the point, 
but with suflicient bulk at the shank to make it reasonably 
rigid. 

As to the best kind of mirror for ordinary use in the mouth, it 
may be stated incidentally that a plane mirror is preferable to a 
magnifying mirror. The latter so distorts the image as to be 
very misleading, while a plane mirror always gives the true image. 
In critical examinations, where the image requires enlargement, 
a good magnifying glass is very useful, but never a magnifying 
mirror. 



CHAPTEK IV. 

EXCLUSION OF MOISTURE DURING OPERATIONS. 

One of the chief hindrances to the execution of perfect work in 
the mouth is the saliva, and the problem accordingly presents itself 
of keeping the teeth free from moisture during operations. Vari- 
ous methods have been employed for this purpose, but in the 
majority of cases the only effective means is by the use of the 
rubber dam introduced years ago by Dr. Barnum. Previous to 
the introduction of the rubber dam the main reliance was upon 
napkins, and, while many operators became very proficient in their 
use, there was never the security that is readily afforded by the 

4 



60 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

dam. Every operator should become an expert in the application 
of the dam, to the end that he may avail himself of its advantages 
in all difficult or complicated cases of treatment or filling. The 
dam is not used as much as it should be by many operators, on 
account of a failure to thoroughly master its ready application, 
and in many cases it is made to work unnecessary hardships on the 
patient through faulty methods of adjustment. It is sufficiently 
unpleasant to most people, even when skillfully used, without add- 
ing to the discomfort by bungling or awkwardness. 

The greatest consideration should invariably be exercised on 
the patient's behalf; not only in the adjustment of the dam itself, 
but in the use of accessories, such as clamps, ligatures, dam-holder, 
weights, etc. Adequate protection to the patient's clothing from 
the overflow of the saliva, particularly when operating upon the 
lower teeth, should be provided in the way of saliva ejectors, nap- 
kins, or a rubber bib. The latter is especially serviceable, and 
should always be at hand for immediate use in an emergency, even 
where it is not deemed necessary to apply it at the outset of the 
operation. The saliva ejector in many instances seems to discom- 
mode the operator, and also to prove with some patients more of 
an annoyance than a relief, though with others it is a very accept- 
able adjunct. The peculiar preferences of patients must be 
studied in this as in other matters. 

Where the ejector cannot be used the chief reliance should be 
the rubber bib, because of the inadequate protection afforded by 
napkins from the tendency of the saliva to soak through and reach 
the clothing. It need not be intimated that the bib must be kept 
scrupulously clean at all times, and thoroughly dried after wash- 
ing before being used on another patient. 

A very agreeable accessory to the use of the dam is a form of 
napkin, Fig. 17, suggested by Dr. J, W. Wassail, to be placed 
between the dam and the chin. The size of this napkin is about 
nine inches square, and the greatest depth of the curvature about 
three inches from the upper margin. Most patients are apprecia- 
tive of this attempt to keep the dam away from the face, and it is 
especially useful in cases where the contact of the dam has a ten- 



EXCLusio::^ of moistuke duehstg operations. 



51 



dencj to induce nausea. The curvature in the pattern fits ap- 
proximately the outline of the mouth, and the two ends may be 
tucked up under the dam-holder, and thus be held in position and 
protect the cheek. In every case where this napkin is not used a 
smaller napkin should be folded and placed between the holder 
and the face on either side, to render the patient comfortable and 
prevent the imprint of the holder being made in the cheek. A 
close observance of these minor details, as they affect the com- 
fort of the patient, will do much toward removing the prevalent 



Fig. 17. 




dread of dental operations, and no operator can afford to neglect 
them, even from the point of view of his own personal ad- 
vantage. 

With individuals who are inclined to be nauseated by the rub- 
ber dam, the difficulty may often be overcome by diverting atten- 
tion from the dam in the following manner: Before applying the 
rubber have everything in readiness to proceed at once with the 



52 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

operation, and the moment the dam is in place go vigorously at 
work upon the tooth with something of a hammer-and-tongs 
method; not necessarily inflicting undue pain, but using sufficient 
force with the instrument to divert the patient's attention from the 
dam to the tooth. Continue this rapidity of action for some 
minutes, ignoring all attempts at protest, and directing every 
energy upon the operation with a quick succession of movements 
and a more or less noisy rattling of instruments. This, if pursued 
for a time, will usually result in the nausea passing away and the 
patient quieting down, but the operation must be carried along to 
completion without any interruptions. If the patient be left for a 
moment, even after the nausea seems to have passed, the sensatiou 
will return instantly when the mind is allowed to dwell upon it. 
This is why the operator must seemingly ignore the symptoms of 
nausea on the first application of the dam, and proceed with the 
work irrespective of it. If he quietly waits for the symptoms to 
pass away they will never pass, but grow progressively worse till 
the dam must be removed. This is only one of many cases in 
dental practice where a bold, rapid, and vigorous policy is the sole 
line of procedure capable of successfully meeting the emergency. 

Kinds of Rubber Dam. 

The weight of the dam is largely a matter of individual prefer- 
ence, some operators preferring a light dam, and others a heavy 
one. The advantages of the light, or thin, dam consist in its more 
ready passage between the teeth, and its consequent greater ease of 
application ; but this is offset by the fact that it will not ordinarily 
remain in place without ligating, and it is too readily caught up 
by revolving appliances, such as disks or burs. The slightest con- 
tact of a rotary instrument with a piece of thin dam will cause it 
to be wound up in the dam so as to tear the dam or puncture it. 
On the other hand, very heavy dam, while ordinarily more diffi- 
cult to apply, will to a greater degree admit of the revolving 
instrument playing over its surface without being wound up or 
injured. It will also remain more securely placed on the teeth, 
and seldom requires ligatures to hold it. But with some teeth the 



EXCLUSION OF MOISTURE DURING OPERATIONS. 53 

contact of the proximating surfaces is such that it becomes some- 
thing of a problem to force thick dam between them, and in gen- 
eral practice it would seem best to employ a medium weight of 
dam. 

As to the relative advantages of the twilled dam and the smooth 
dam, the operator has his choice between a dam which remains 
well in place when once adjusted, but which annoyingly catches 
on every instrument or appliance coming in contact with it, and 
one which may not be quite so tenacious to the tooth, but which 
admits of reasonable usage without annoyance. The twilled dam 
seems to have an especial propensity for being caught up by every 
movement of an instrument against it, and, while there are some 
operators who use it successfully and with evident satisfaction, it 
will prove too troublesome for general recommendation. 

Size of Dam. 

The size varies according to the particular case in hand, and the 
location in the mouth. For the molars it should be about seven 
inches square, and ranging from this down to six inches for the 
incisors. Some operators prefer the dam cut in the form of a 
triangle by dividing a square piece in two from one corner to 
another, the long base of the triangle being placed uppermost and 
the ends grasped by the dam-holder, while the apex hangs do%vn 
over the chin. This is an economical way of cutting the dam, 
and answers a good purpose in the anterior part of the mouth, but 
for posterior teeth the square form is preferable. 

Punching the Holes. 

The various forms of rubber-dam punches may be used for 
making the holes, but in case a punch is not available a very simple 
and very effective method is as follows: Take a round instru- 
ment handle about four millimeters in diameter, slightly oval- 
faced on its end, and perfectly smooth. Over this stretch the 
dam, with some tension at the point where the hole is desired, and 
with a sharp knife nick the dam against the side of the handle a 



54: PEINCIPLES AND PKACTICE OF FILLING TEETH. 

short distance from the end. This will invariably cut out a per- 
fectly round piece of rubber and leave a hole as true and clean in 
outline as is possible with the sharpest punch. The size of the 
hole may be gauged accurately by the distance from the end of 
the instrument at which the cut is made. If it is near the end, the 
hole will be small; if farther away, it will be correspondingly large. 
In this way it is possible to vary the size of the hole from the 
smallest perceptible puncture to a hole the size of a lead pencil, 
and still have a clean-cut outline. 

The sizes required for the different teeth will vary from about 
three millimeters in diameter down to one millimeter, and a little 
practice will enable the operator to cut the holes precisely as 
desired. The width of rubber between the holes must vary ac- 
cording to the width of the interproximal spaces and the condi- 
tion of the gum-septum occupying them. If the teeth are long- 
crowned, with the contact point near the occlusal surface and the 
interproximal space large and imperfectly filled with gum-tissue, 
the width of dam between the holes must be great; while if the 
teeth are short, with small interproximal spaces and the gum 
coming up to the contact point, there is little room for the dam 
between the teeth, and it must be correspondingly narrow. But 
it should never be made so narrow that it fails to adequately cover 
the gum-septum and shut out moisture. If too narrow, it will, 
when stretched between the teeth, pass down to one side of the 
gum-septum and pinch it against the proximal surface of the 
tooth, leaving part of the gum exposed to view, instead of having 
it wholly covered. The width of dam between the holes should 
vary from two to four millimeters in medium-weight rubber, — the 
lighter the rubber, the greater the width necessary. This has no 
relation to cases of unusual spaces between teeth where the 
proximal surfaces are not in contact, and where the width of dam 
must be governed by the extent of separation. 

Rubber-Dam Clamps. 

The use of clamps for the purpose of holding rubber dam in 



EXCLUSION OF MOISTURE DURING OPERATIONS. 55 

place upon the teeth has been much misunderstood and greatly 
abused. Clamps, if properly selected and carefully adjusted, are 
capable of a wide range of usefulness, but if employed without a 
knowledge of their limitations and in direct violation of the neces- 
sary care and skill, as they frequently seem to be, they are calcu- 
lated to work irreparable injury to the teeth and surrounding parts, 
and involve the patient in much needless suffering. 

The principal faults in the manipulation of clamps consist in a 
failure to select the suitable form of clamp for the case in hand, 
and a lack of care in its proper adjustment. A clamp that does 
not approximately fit the tooth cannot be expected to effectively 
remain in position without undue impingement at certain points, 
which results in injury and discomfort. An operator should have 
a sufficient number of forms to meet the varying cases presented 
in the mouth, and to this end should make a careful study of the 
different teeth with especial relation to the shapes of the crowns 
and necks, so as to be able to make his selection of clamps with 
intelligence. In the adjustment of a clamp harm may be done 
in two ways: the clamp may be too small for the tooth and pinch 
it so severely at the neck as to injure the tooth, especially in a 
long operation where the slight movement of the clamp resulting 
from the pressure of the rubber dam against the bow may cause 
the sharp beaks to grind against the enamel so as to indent it; or 
the clamp may work so far rootwise on the tooth as to cause im- 
pingement on the gum and set up serious inflammation. Even if 
this injury is not always permanent, it is sufficiently distressing to 
the patient to account for future distrust and apprehension when- 
ever the clamp is employed. 

The rubber dam itself is sufficiently objectionable to the average 
individual without adding to the dread by painful methods of 
application, and, while it is not always possible to maintain the 
dam in place without some slight discomfort, there is no excuse 
for inflicting the serious injury in its use that is too often done by 
careless operators. The clamp may be used in the large majority 
of cases without perceptible pain or other ill effects, if properly 
selected and skillfully applied. The two classes of teeth most 



56 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

difficult to manage in tliis regard are those of the extreme bell- 
crowned variety, where the crowns are exceedingly long with 
broad occlusal surfaces, and the short conical teeth appearing very 
little above the gum. In the former case the contact points on 
the proximal surfaces are near the occlusal surface, and the inter- 
proximal spaces are large and long. The tooth at the gingival 
line is much narrower in circumference than at the occlusal sur- 
face, and the buccal and lingual surfaces accordingly present an 
incline toward the gum. The ordinary clamp applied to a molar 
or bicuspid of this type has a tendency to slide along this incline 
and gradually impinge seriously upon the gum. Every movement 
of the rubber dam against the bow of the clamp tends to force it 
still farther along the incline, till it becomes excruciating to the 
sensitive gum-tissue. To obviate this difficulty clamps have been 
devised with stays on the bows to rest on the occlusal surface of 
the tooth, with the idea of preventing the clamp from slipping 
too far rootwise, but in many cases these stays do not prevent the 
clamp from tipping forward and gouging the anterior point of the 
beak in the gum, and in other cases the stays are in the way of the 
operation. The better method where these extreme bell-crowned 
teeth are encountered is to dispense with the clamp altogether and 
secure the dam by some other means. 

The other form of tooth, in which the crown is short and the 
tooth much larger in circumference at the free margin of the gum 
than at the occlusal surface, presents difficulties of a vastly dif- 
ferent character. In this case the incline is from the gum toward 
the occlusal surface, and the chief problem presented is to main- 
tain a clamp in position at all. The inevitable tendency is to dis- 
lodge the clamp by the slightest movement, and unless the clamp 
is made secure in the beginning of the operation an intricate piece 
of work may be jeopardized, and even ruined, by dislodgment of 
the clamp when the operation is only partially completed. In this 
instance there is little danger of injuring the tooth or the gum 
with the clamp. It may cause temporary discomfort, but seldom 
permanent injury. The gum covers the enamel to such an extent 
that the enamel is thick at the point where the clamp rests, and as 



EXCLUSION OF MOISTURE DURING OPERATIONS. 57 

for the gum, it will usually be found lapping over the surface of 
the tooth to a considerable distance from the point where it is 
attached to the root. This flap of overlying gum may safely be 
forced back by the clamp at several points sufficiently to admit a 
grip of the beaks without permanent injury, provided it is not 
pinched by the beaks or severely lacerated. If necessary, a local 
anesthetic may be used on the gum before applying the clamp, 
and after the operation an anodyne antiseptic should be applied 
and the gum gently kneaded against the buccal and lingual sur- 
faces with the finger. 

For extremely difficult cases of this character, such as are some- 
times encountered in stunted third molars, a specially devised 
clamp is indicated, to be referred to subsequently. 

With the exception of these two classes of teeth, and the peculiar 
difficulties experienced in the management of labial, lingual, or 
buccal cavities, the ordinary use of clamps, if properly adjusted, 
ought not to be a serious dread to the patient. 



KINDS OF CLAMPS. 

Clamps for Molars and Bicuspids. 

In the application of the rubber dam to molars and bicuspids, 
the chief problem in the past has related to the difficulty of carry- 
ing the rubber back over the teeth and holding it there while the 
clamp was being adjusted. To carry the dam to place with the 
fingers, particularly over teeth far back in the mouth, was exceed- 
ingly awkward, and in some cases almost impossible without dis- 
tressing the patient. To overcome this, operators were in the 
hal)it of passing the beaks of the clamp through the hole in the 
dam and carrying the clamp and rubber to place at once, after- 
ward lifting the nibber over the beaks and passing it between them 
and the gum. The drawback to this, with beaks of the ordinary 
form, was the fact that the rubber stretched across the opening 



58 PEINCIPLES AND PRACTICE OF FILLING TEETH. 

between tlie beaks and obscured the tooth so that it was difficult 
to see where the clamp was being placed, A new form of clamp 
was devised to obviate this, known as the Ivory clamp, in which 
the beaks are carried out buccally and lingually and then turned 
down into a flange, over which the rubber may be hung, leaving 
the space between the beaks open for perfect vision. "With this 
form of clamp the application of the rubber dam is a very simple 
matter, as will be detailed later. 

Another advantage of this clamp is the projecting forward of 
an extension from each beak to hold the rubber out of the way 
during an operation. In this connection it may be stated that 
one of the chief offices of the clamp, aside from its service in main- 
taining the rubber on the tooth, is to keep it away from the region 
of the cavity, so that it shall not constantly be in the operator's 
light and be caught up with instruments and displaced. The bows 
of the clamp accomplish this distally, and the projections on the 
beaks of the Ivory clamp do it buccally and lingually. Figs. 18 
and 19 illustrate the Ivory clamp with the flanges referred to and 
the manner of hanging the rubber over them. Fig. 20 is a special 
form of beak which will be found very serviceable for those diffi- 
cult cases previously referred to, — the short conical teeth whose 
buccal and lingual surfaces incline sharply toward each other as 
they pass from the gum-margin to the occlusal surface, so as to 
lead to the displacement of an ordinary clamp. As will be seen, 
the extremities of the beaks are deflected in such a way as to dip 
under the free margin of the gum and grasp the tooth well root- 
wise. This clamp would be an exceedingly cruel device to use 
in ordinary operating, but for these especially trying cases it will 
securely maintain the rubber in place when no other form of 
clamp is effective, and if used with discriminating care it need 
not be productive of any serious injury or discomfort to the 
patient. 

The operator should have a large assortment of special forms of 
clamps to meet all the special cases, but for ordinary use a few of 



EXCLUSION OF MOISTUKE DURING OPERATIONS. 



59 



the standard forms of molar and bicuspid clamps mil do the major 
part of the work in the routine of office practice. 



Fig. 18. 



Fig. 19. 





Fig. 20. 




Cervical Clamps for Buccal, Labial, or Lingual Cavities. 

With the large range of service demanded of a cervical clamp 
and the intricate positions it is sometimes called upon to reach, it 
could scarcely be expected that any one form of clamp would 
advantageously cover all cases. Much improvement has been 
made in recent years in the development of the cervical clamp, 
and some of the more modern forms would seem to be as nearly 
universal as ingenuity can make them ; but for the average practi- 
tioner it will be found best to have several varieties to meet all of 
the emergencies that may present. Some operators seem to have 
a special aptitude for one particular kind of clamp, and are ap- 
parently able to accomplish more with it than with any other; but 
for most men it will be necessary to have at least three or four 
forms to secure the best results. 

The forms here illustrated are not intended to include all of the 
serviceable clanips in the market, but with these in his case the 



■60 



PKINCIPLES AND PRACTICE OF FILLING TEETH. 



■operator will be reasonably well equipped to meet most cases apply- 
ing to him for treatment. Fig. 21 is the Keefe clamp, a feature 
-of which is the triple bearing on the tooth aiforded by the three 
jaws or beaks. This tends to hold the clamp securely in place and 
prevent rocking when screwed down snug with the set-screw. To 
provide for different lengths and forms of teeth and the various 
positions of cavities two of the beaks are made adjustable, by which 
means the clamp has a wide longitudinal range on the tooth, so 
as to be carried well rootwise in cases of extensive caries. In 
using this clamp it should first be carefully adjusted to the tooth 



Pig. 21. 




Fig. 22. 



Tig. 23. 





before the rubber is in place, so that the operator may clearly see 
all of the bearings and set the movable beaks in the correct posi- 
tion. It may then be taken from the tooth, the rubber adjusted, 
and the clamp returned to place, after which the set-screw may be 
turned down tight to hold the clamp firm. 

Fig. 22 represents the Dunn clamp 'No. 2, which is intended to 
be as widely universal as possible. The bows are strong and rigid, 
so as to gain security of retention when the set-screw is tightened. 
In cases of extensive decay rootwise the beak may be carried 
beyond the cavity by placing a thick pad of bibulous paper 
between the opposite beak and the gum, against which the clamp 
may be tightened without injury to the tissues. This pad will 
enable the operator to give the clamp a wide range of position, and 



EXCLUSION OF MOISTURE DURING OPERATIONS. 61 

should be employed in most cases where the clamp is used. The 
clamp should be loosely placed upon the tooth with the pad under 
the lingual beak, and then the labial beak gently forced to posi- 
tion and the clamp tightened with the set-screw. In case the arch 
of the teeth in the cuspid region interferes with the bow, the clamp 
may be reversed and used with the bows looking in the opposite 
direction. 

Fig. 23 is the Libby clamp, made in a right and left. The dis- 
tinctive feature of this clamp is the hinged beak or pivoted shoe 
on the lingual extremity, which enables the clamp to readily seek 
a bearing and remain fixed in any position where it is placed. This 
clamp should be carried to position with the Brewer clamp forceps, 
Fig. 24; and when once properly adjusted it maintains its place 
very satisfactorily, on account of the broad bearing provided by 
the hinged apparatus on its lingual aspect. The fact that the 
extremity of this usually rests against the gum renders it desirable 
to protect the gum from too great pressure by slipping a short sec- 
tion of half -inch rubber tubing over it before applying the clamp. 
With this rubber pad properly adjusted there is never any com- 
plaint from the patient, and it does not seem to interfere with the 
security of the clamp. 

A careful study of the proper method of using the three kinds 
of clamps here illustrated will enable the operator to successfully 
meet the most difficult cases which apply to him for treatment, and 
will render the average cases very easy of control. In some in- 
stances the clamp will need to be steadied by the fingers of the 
operator to make certain that there shall be no movement, but the 
usual length of time necessary to complete an operation of this 
kind ought not to be sufficiently long to make this especially 
irksome. 

Ligatures. 

In operating on proximal cavities in the anterior teeth where 
clamps are not indicated, or in cases of bell-crowned molars and 
bicuspids where the clamp would prove too cruel, ligatures may 
be used for the retention of the dam to good effect. The most. 



62 PEINCIPLES AND PEACTICE OF FILLING TEETH. 

Fig. 24. 




EXCLUSION OF MOISTUEE DURING OPERATIONS. 63 

serviceable kind of ligature is waxed floss silk, on account of its 
great strength in relation to its bulk, thereby admitting a suffi- 
ciently strong ligature to be readily forced between the teeth. 

In cases where the dam has a tendency to be dragged over the 
ligature and become displaced, leaving the ligature on the tooth, 
the difficulty may be overcome by the use of small glass beads 
strung on the ligature and distributed at various points around the 
tooth. On a molar, for instance, where the tendency would be 
greatest for the dam to slip, a bead may be placed respectively at 
the disto-buccal, the disto-lingual, the mesio-buccal, and the mesio- 
lingual angles of the tooth, and these beads will present sufficient 
bulk to resist the displacement of the dam. In lieu of beads Dr. 

Fig. 25. 




E. K. Wedelstaedt has suggested the tying of a small roll of cot- 
ton in the ligature, and thus creating bulk. The manner of 
adjusting the ligature is to force it between the teeth on the distal 
surface of the tooth to be ligated, pass it around the lingual sur- 
face, and out buccally or labially, as the case may be, between the 
mesial surface of this tooth and the distal surface of the one next 
in line. The two ends of the ligature now extend out so the 
operator may readily grasp them, but the portion embracing the 
tooth is usually not far enough rootwise. Before attempting to 
force the ligature to place the first loop of a surgeon's knot should 
be formed, like Fig. 25, by passing one end of the ligature twice 
around the other, instead of once. This kind of a knot will hold 
firm when drawn tight against the tooth to a greater degree than 
where the ordinary knot is used, and will thus admit of the second 
loop of the knot being tied without the ligature loosening. Before 



64 PEIlSrCIPLES AND PRACTICE OF PILLING TEETH. 

drawing the first loop tight the ligature should be forced as far- 
rootwise on the lingual surface as is desired with an instrument^ 
and while being held there the strands of the ligature may be car- 
ried well into the interproximal spaces by gentle force on the free 
ends exerted in an oblique direction buccally (or labially) and 
slightly rootwise. When the ligature on the mesial and distal 
sides of the tooth has glided under the free margin of the gum and 
carried the dam with it the first loop of the knot may be drawn 
tight, which will securely fix the ligature and dam in place till the 
second loop of the knot is tied. This second loop need not be 
double-twisted, as the first. When the ligature is thus tied the 
free ends may be cut near the knot, preferably with a small 
curved pair of scissors like manicure scissors. 

A very effective method of ligating teeth has been devised by 
Dr. Wedelstaedt and kno^\Ti as the "Wedelstaedt tie." In this 
method the double twist, as shown in Fig. 25, is located on the 
lingual surface of the tooth instead of on the buccal or labial, and 
the two ends of the ligature are again passed between the contact 
points so as to extend out through the interproximal spaces buc- 
cally or labially. The ligature is then tightened around the tooth 
by grasping the ends and forcibly exerting traction on them by 
a slight movement of the hand back and forth. This will snug 
the ligature up into the interproximal spaces so as to grip the tooth 
most effectually, and when tied again across the buccal or labial 
surface it furnishes a double-stranded ligature completely en- 
circling the tooth and securely holding the dam in place. 

The forcing of a ligature to place is to some patients painful, 
while others do not seem to mind it in the least, the difference be- 
ing due to the natural sensitiveness of certain patients more than 
others, and also to the fact that in some conditions of the gums 
there is an undue tenderness to pressure even when the individual 
is not otherwise nervous. The fact that the ligature in any in- 
stance may give pain should influence the operator to dispense with, 
it whenever possible, and in actual work in the mouth this may be- 
done to a very large degree. If the dam is of the proper weight 
and is skillfully adjusted it is the exception, rather than the rule.. 



EXCLUSIO^' OF MOISTURE DURING OPERATIONS. 65 

for a ligature to be required. The chief problem of retaining 
the dam in place without a ligature consists in so applying the 
dam that the edges of the holes are curled up under the free mar- 
gin of the gum and look rootwise instead of crownwise. If this 
can be accomplished, the rubber will ordinarily remain in place 
and prevent leakage without a ligature. To do this the dam 
should be stretched rootwise by placing the ends of the fingers over 
the dam on the buccal (or labial) and lingual sides of the hole, and 
forcing it against the gum and toward the root. If, on being 
released, the dam does not curl up to position as desired, it may 
often be tucked to place with a smooth blunt-edged instrument 
like an amalgam spatula by stretching the dam rootwise and sweep- 
ing the instrument obliquely along under the edge of the dam as 
it is being released. Where this is not effective the dam may 
readily be curled under by ligating the tooth, a procedure which 
will invariably result in turning the edges of the dam so that they 
extend rootwise. If it is a case where there is objection to the 
ligature, or where the ligature does not seem necessary for retain- 
ing the dam, it may be immediately removed after the rubber has 
been carried to place. 

Occasionally it is necessary to ligate only one or two teeth in a 
given series embraced by the dam. The tooth to be operated on 
will usually require ligating to secure the maintenance of the 
rubber in its proper place and prevent leakage, unless a clamp is 
being used. If the cavity is a proximal one it is often neces- 
sary to ligate the tooth next in line, so that the strip of dam in the 
interproximal space will be held well out of the way and any 
possible oozing of moisture under the margin of the dam avoided. 
The last tooth embraced by the dam and farthest from operation 
may also require ligating to prevent the rubber from being 
dragged away by the action of the lips or the tongue, though it 
will frequently be found that ligating can be dispensed with in 
such a case by merely drawing between the proximal surface 
of this tooth and the rubber as it hangs up over the tooth not 
embraced by it a single strand of the ligature and cutting it off, 
allowing a piece of the strand about five or six millimeters in 

5 



66 



PRINCIPLES AND PRACTICE OF FILLING TEETH. 



length to hang as a wedge between the dam and the tooth last 
Fig. 26. embraced. In case there is too much space between the 
teeth to render the strand effective, a piece of rnbber 
may be substituted for it by using an ordinary elastic 
band of suitable size, stretching this to place, and cut- 
ting it the proper length. 

In cases where there is appreciable recession of the 
gums, leaving the interproximal spaces somewhat open 
and admitting a certain amount of movement to the 
dam between the teeth, the tendency is often great for 
the dam to leak unless it is held against the gum and 
kept from movement. To ligate all of the teeth is 
usually more or less distressing to the patient, besides 
consuming time. A much less painful and a more 
rapid method is to pack a bit of cotton in each inter- 
proximal space between the contact points of the teeth 
and the rubber, forcing the cotton well up toward 
the contact points so that it will remain wedged to 
jDlace. This will usually be quite effective in holding 
the rubber to position against the gum, and, if done 
with care, need not give the patient the slightest dis- 
comfort. The operator should never forget to remove 
these little cotton plugs before attempting to take off 
the dam, otherwise he is likely to give a rather uncom- 
fortable pull to the dam without removing it. 

In every instance where there is the slightest doubt 
about the dam passing readily between the teeth, a liga- 
ture or strip of rubber should first be carried between all 
of the teeth to be embraced by the dam, to make certain 
that the spaces are clear and free from rough or sharp 
edges calculated to cut the dam. Sometimes bits of cal- 
culus are found on the proximal surfaces, and these 
should invariably be removed before the dam is ap- 
plied. In other cases incipient caries may have be- 
gun near the contact point on teeth other than the 
one being operated on, and the sharp margin of the 



EXCLUSION OF MOISTUKE DURING OPERATIONS. 67 

cavitr may cut the ligature or rubber. To obviate this a thin 
broad instrument like the gum-depressor, Fig. 26, should be forced 
between the teeth with a see-samng motion, so as to smooth the 
rough or jagged edges of enamel in advance of the application of 
the dam. This instrument may be readily passed between the 
contact points of the teeth, especially if the edge has been ground 
quite thin, and after its free passage the dam may lie applied with 
safety. 

"When the teeth are thus prepared for the reception of the dam, 
a general survey of the situation should be made to determine the 
required location of the holes. For the lower molar teeth the last 
hole l)ack should be about three inches from the upper edge of 
the dam, and about two and one-half or three inches from the 
edge on the side of the operation, though this may vary some- 
what according to the shape of the jaws and lips of the patient. 
For lower bicuspids the holes may be somewhat nearer either edge, 
but in no instance should they be near enough to prevent the dam 
from properly covering the upper lip and angles of the mouth. For 
the upper molars or bicuspids the last hole back need not be more 
than two inches from either side.; Following this point forward, 
the holes should be cut so as to correspond with the curve of the 
arch, and in every instance a sufficient number of teelh should be 
included in the dam to properly expose the operation to view and 
keep the dam well out of the operator's way. It is too frequently 
the case that operators hamper themselves in their work by includ- 
ing only one or two teeth in the dam, thereby allowing the ^lam 
to curl up about the cavity and hide it from view, besides risKing 
the danger of continually catching the dam in burs or other revolv- 
ing instruments. There may be occasional instances where, on 
account of the difficulty of applying the dam, it is justifiable to 
limit as far as possible the number of teeth to be embraced by it, 
but under ordinary conditions in operating upon the molars 
or bicuspids the dam should be made to include the teeth as far 
forward as the lateral or even the central incisor. Aside from the 
idea of having the dam well out of the way, there is an anatomical 
reason for ending at one of the incisors. To end at the cuspid 



68 PRINCIPLES AjN^d practice of filling teeth. 

would often afford the operator ample opportunity for work, but 
the form of this tooth is usually such as to render it unsuited to be 
the last tooth embraced by the dam. It is often so cone-shaped 
that the dam readily draws away from it, while the mesial sur- 
faces of the incisors ordinarily present such an incline as to prove 
an excellent medium over which to hang the last hole of the dam. 

Manner of Applying the Dam in Different Locations in the Mouth. 

Before applying the dam to any of the teeth the enamel should 
be made clean by a thorough rubbing with absolute alcohol on a 
pellet of cotton to remove any debris which may be clinging to 
the teeth or lodged at the gum margin. Unless this precaution is 
taken, the debris containing micro-organisms may be forced under 
the free margin of the gum by the dam and cause undue soreness 
through infection, by being held in contact with the soft tissues 
during the operation. 

To apply the dam to the lower bicuspids and molars the operator 
should first select a suitable clamp to fit the last tooth back to be 
included in the dam, and, after hanging the dam over the flanges 
of the clamp and adjusting the clamp forceps, he should grasp 
the upper edge of the dam with the thumb and fingers of the left 
hand in such a way as to stretch the dam up against the bow of 
the clamp and hold the edges well out of the way of perfect vision 
during the application. Then, standing to the right and slightly 
in front of the patient, with the chin raised sufficiently to look 
directly into the mouth, the clamp with dam attached should be 
carried to place upon the tooth. The clamp should be adjusted 
with the utmost delicacy and gentleness, so as to inflict the least 
possible discomfort. In some instances the first grip of the clamp 
on the tooth will cause a slight flinching on the part of the patient, 
but if it is a clamp of the proper form for the case in hand and is 
carefully applied all appreciable discomfort passes away in a 
moment. Immediately following the placement of the clamp the 
forceps should be laid aside and a pair of pliers or a thin-bladed 
spatula should be employed to lift the rubber free from the 
flanges of the clamp, so as to let it snap around the tooth. The 



EXCLUSION OF MOISTURE DURING OPERATIONS. 69 

dam thus fixed, the edges may be fastened back out of the way, 
with the dam-holder around the patient's head, when both hands 
will be free for the further adjustment of the dam over the remain- 
ing teeth. With the number of holes in the dam already fixed 
in his mind, the operator should count back toward the tooth 
embraced by the clamp to be assured that he is placing each hole 
over the proper tooth, otherwise he may make the mistake of 
leaving a hole in the dam between the tooth embraced b}^ the 
clamp and the one in front of it. Then, starting at the tooth next 
to the one already exposed by the clamp, he should consecutively 
pass the rubber over each tooth till all are included. This should 
be done by forcing the edge of the dam bordering the hole past the 
contact points, and thus carrying the strip of rubber between the 
holes into the interproximal space. If at any point the rubber 
seems to stick and refuses to pass between the teeth short of suffi- 
cient stretching to risk the danger of tearing the dam, the rubber 
should be merely hung over this particular tooth while the operator 
passes to the others and slips the dam over them. Then the 
ligature may be used to force the dam past the difficult spaces, and 
a careful examination made to see that there are no points at which 
a leak may occur. In doing this the distal surface of the tooth 
embraced by the clamp must not be overlooked. If the dam hangs 
over this tooth so as to invite leakage, the ligature should be used 
to carry the dam well between this tooth and the one Iwck of it. 

After the proper adjustment of the dam the comfort of the 
patient must be looked to, as previously indicated, by the use of 
napkins, cheek pads, rubber bibs, etc. If the lower edges of the 
dam exhibit an inclination to curl up in the operator's way, they 
may be fastened down by weights. 

In applying the dam to the upper bicuspids and molars the plan 
of procedure is much the same as for the lower teeth, except that 
some of the motions must be reversed, and the position of the 
patient and operator slightly changed. The grasp of the clamp 
forceps is also different. When adjusting the clamp to the lower 
teeth the forceps is placed with the claws looking downward, and 
the handles are grasped in tlie palm of the hand with the back of 



70 



PRINCIPLES A^T> PKACTICE OF FILLING TEETH. 



the hand upward and the thumb pressing against the outside of the 
handle nearest the operator close to the hinge, while the fingers 



(P 



IS. 



reach over the clasp the handle farthest from the operator. 
27.) 

For the upper teeth the claws of the forceps look upward and 
the back of the operator's hand downward. The handles of the 



Fro. 27. 




forceps pass diagonally across the palm between the second and 
third fingers and out between the thumb and index finger, so that 
the handles near the end are grasped by the thumb and index 
finger, and farther do's\ai toward the hinge by the second and third 
fingers. The ends of the index and second fingers clasp around 
and over the top of the handle farthest from the operator, while 
the thumb clasps around and over the top of the handle nearest 
him, and the ends of all three are turned so as to look somewhat in 
the direction of the claws. Thus the only finger not touching the 



EXCLUSION OF MOISTURE DURING OPERATIONS. 



71 



forceps is the little finger, and the principal grasping force is 
exerted by the index finger and the thumb, while the lifting force 
in carrying the clamp to place is exerted by the third finger as the 
handle lies across it. (Fig. 28.) 

In adjusting the dam to the upper teeth the patient's head 
should be tipped back so as to expose these teeth as perfectly as 

Fig. 28. 




possible, and for the right side of the mouth the operator should 
stand to the right and in front of the patient with the patient's 
head slightly turned to the right, so as to present the occlusal sur- 
faces of the teeth directly toward the operator, the chin being 
raised to a convenient height for this purpose. 

On the left side of the mouth the teeth can often be better ap- 
proached by slightly lowering the chair and stepping a trifle to the 



72 PRINCIPLES AND PBACTICE OF FILLING TEETH. 

back of the patient, so as to pass the left hand and arm over and 
around the patient's head to hold the upper edge of the rubber 
away while the right hand is manipulating the forceps. The 
operator should study carefully the various peculiarities of form 
and position presented by the different mouths and teeth of indi- 
viduals, so as thereby to avail himself of every advantage which 
his ingenuity may suggest. There is always a best and handiest 
way of doing these things, but no one way is always the best nor 
the handiest, and to gain the most satisfactory results in every case 
the operator must be prepared to vary his methods, so far at least 
as the minor details of execution are concerned. 

For the upper incisors and cuspids the holes should be punched 
in the dam from an inch and a half to two inches from the upper 
edge, depending on the case. The former distance will be ample 
in most instances, but for a gentleman patient with a large 
moustache the holes should be at least two inches from the edge, 
to afford sufficient area of dam to perfectly cover the moustache 
and hold it out of the way. In no case should the dam be allowed 
to pass over the nostrils and obstruct the patient's breathing. For 
the lower anterior teeth the holes should be from three inches to 
three inches and a half from the upper margin, so that the mouth 
may be thrown well open and still admit of the dam extending 
over the upper lip. 

To adjust the rubber to the upper anterior teeth the upper edge 
of the dam. should be grasped by the left hand in such a manner 
that the back of the hand looks away from the patient's face, while 
the palm is turned toward the face and the ends of the fingers 
look downward with the elbow raised over the patient's head. 
The dam should pass between the thumb and index finger and out 
again between the third and little fingers, so that the index, second, 
■and third fingers are exposed to the operator's view as he looks at 
the back of his hand while the ends of the thumb and little finger 
are covered by the dam. The grasp of the dam therefore comes 
in two places, between the thumb and index finger and between 
the third and little fingers, thus keeping the dam on a tension and 
leaving the second finger free to stretch the holes. The end of 



EXCLUSION OF MOISTURE DUEI^'G OPERATIONS. 73 

the second finger should be placed at the upper margin of the hole 
which is to embrace the tooth farthest to the left, and opposite 
this, on the lower margin of the same hole, should be placed the 
end of the index finger of the right hand, while the rubber extends 
from this down into the palm of the right hand and is grasped by 
gathering the edge nearest the operator between the thumb and 

Fio. 29. 




palm on the one side and the second, third, and little fingers on 
the other, the thumb extending between the dam and the patient's 
chin, while the ends of the fingers are curled well up into the palm 
to readily bring the rubber on a tension. This leaves the index 
finger free to work in conjunction with the second finger of the 
left hand in stretching and forcing the holes over the teeth. 
(Fig. 29.) 

Beginning with the tooth farthest to the left, the dam should 
be carried consecutively over each tooth toward the right till all 
are included. The strips of dam between the holes should be 



74 PEINCIPLES AND PRACTICE OF FILLING TEETH. 

forced well into tlie interproximal spaces by a see-sawing or 
stretching motion exerted by the second finger of the left hand 
and the index finger of the right, so that if possible the 
edges of the dam around the holes are turned under the free 
margin of the gums and look rootwise. The outer edges of the 
dam may now be fastened back with the holder, after which liga- 
tures may be applied wherever necessary, and the comfort of the 
patient looked after as previously indicated. 

For the anterior teeth of the lower jaw the grasp of the rubber 
in the left hand is practically the same as for the upper teeth, but 

Fig. 30. 




the grasp with the right hand is entirely different. Instead of 
gathering the edge of the dam nearest the operator in the palm, 
the grasp is made from the lower margin of the dam with the 
thumb uppermost. The grip is exerted by curling all four fin- 
gers up into the palm and gathering the lower edge of the rubber 
between the ends of the fingers and the palm. This leaves the 
thumb free to stretch the holes over the teeth in conjunction with 
the second finger of the left hand (Fig. 30). But the method of 



EXCLUSION OF MOISTURE DURING OPERATIONS. 75 

forcing the dam to place is different from that of the upper teeth. 
When stretching the holes over the upper teeth the end of the 
second finger of the left hand is carried along the labial surface 
of the tooth, while with the lower teeth it is carried into the mouth 
and along the lingual surface, the thumb forcing the dam over 
the labial surfaces. 

To gain an intelligent conception of the methods of procedure 
here outlined, both as regards the handling of the clamp forceps 
and the various grasps of the rubber dam, the beginner would 
better follow out the descriptions with the forceps and dam in his 
hands. It is too often the case that descriptions which read well 
prove impracticable when applied to the mouth, while methods 
which appear cumbrous in print are very effective in their practi- 
cal application. It is with this idea in mind that, in conjunction 
with the writing of these descriptions, an actual adjustment of the 
dam has been made in each instance. 

Applying the Dam for Operations on Buccal, labial, or Lingual 

Cavities. 

The peculiar difficulties to be encountered in controlling these 
cases relate to the rootwise extension of the decay, and the conse- 
quent involvement of the gum-tissue in the cavity. In some in- 
stances the gum fills more than one-half the cavity, and the prob- 
lem then is to displace the gum so as to expose the gingival margin 
of the cavity and admit of carrying the clamp and rubber rootwise 
of it. This may be done in one of several ways. Where a large 
mass of hypertrophied gum-tissue fills the cavity it should be cut 
away with a lancet or curved scissors, and then the cavity packed 
with gutta-percha in the form of a soft temporary stopping, with 
considerable excess extending over the gingival margin of the 
cavity so as to force the gum well away from this region. This 
should be allowed to remain two or three days, when the gum will 
be found well healed and the cavity-margin exposed. In many 
cases the temporary stopping will accomplish the object without 
previous cutting of the gum, and in case it is difficult to maintain 
in place, on account of the form of the cavity, it may be secured 




76 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

by passing a ligature around the tooth and over the gutta-percha, 
thus tying it to position. 

In some cases the decay extends over the surface of the tooth 
and under the gum for considerable distance without appreciable 
penetration into the tooth, so that gutta-percha cannot in any way 
be employed to force back the gum. The only alter- 
FiG. 31. native is to press away the gum with the clamp at 
the time of operating, or, if this cannot be done, to 
make a vertical incision in the gum over the cavity, 
reaching from the gum-margin rootwise past the de- 
cay. The flaps of gum may then be forced out of 
the way, and after the filling is completed they will 
readily heal, provided care is taken not to produce 
too much laceration. (Fig. 31.) 
The operation should be performed with antiseptic precaution, 
and after the clamp is removed the flaps of gum should be gently 
kneaded into position vsdth the fingers and held with the severed 
edges pinched together for a few minutes. The patient should 
be warned against using the tooth-brush upon the gum till it is 
perfectly healed, but in the meantime to bathe it with an anti- 
septic mouth-wash several times a day and gently massage it over 
the filling. 

With the gingival margin of the cavity thus exposed one of the 
chief diflSculties in the application of the dam is removed, but a 
minor one instantly presents itself in the fact that the cavity 
extends so much farther rootwise than the gum on the opposite 
side of the tooth that the jaws of the clamp do not impinge on the 
tooth at points directly opposed to each other. This results in 
insecurity of the clamp unless specially provided for. With the 
Keefe clamp this difficulty is overcome by the adjustable jaws 
and the triple bearing, in the Libby by the pivoted shoe for the 
lingual surface, and in the Dunn by the use of the gum pad, so 
that the points of bearing may be arranged directly opposite one 
another. It is of the utmost importance to test the various 
clamps on the tooth before the application of the dam, so that a 
suitable selection may be made for the case in hand. 



EXCLUSION OF MOISTURE DURING OPERATIONS. 77 

In making holes in the dam for these cavities they should be 
punched farther apart than for other cavities, so as to admit of 
considerable stretching of the strips between the holes without 
drawing them too thin or too narrow. 

Application of the Dam in Difficult Cases. 

It is seldom that the dam cannot be readily applied to any of the 
anterior teeth and securely retained in place, but with the molars, 
particularly the second and third molars, the problem sometimes 
becomes more or less complicated. The chief difficulties relate to 
peculiar forms of teeth, unfavorable positions of teeth, bad con- 
tacts on the proximal surfaces, and a general tendency to resist- 
ance on the part of the patient. 

The forms of teeth most unsuited for the retention of the clamp 
are those of a cone-shape, with buccal and lingual surfaces so 
sloped that the clamp is invariably displaced unless made of a 
peculiar pattern. Teeth of this character are much larger in cir- 
cumference at the gum-margin than at the occlusal surface, and 
there is consequently no opportunity for the grip of an ordinary 
clamp. But if a close study be made of these teeth it will usually 
be found that a short distance under the free margin of the gum 
there is a slight depression as the enamel approaches its thin edge 
near the cementum. The gum is never adherent to the tooth at 
this point, and with a clamp so formed that the jaws are turned 
down into a reasonably sharp projection at either extremity, so 
as readily to slip under the free margin of the gum, an adequate 
grip may be obtained, provided the patient w^ill submit to a slight 
temporary discomfort. Such a clamp has already been referred 
to in Fig. 20, and if this clamp is used with discriminating judg- 
ment it will be found very effective without the infliction of any 
serious pain. It should be applied with the Brewer forceps, 
the bows of the clamp necessarily being very rigid and the jaws 
not readily spread with the ordinary forceps. 

Unfavorable positions of the tooth relate particularly to upper 
third molars which are turned outward so that their occlusal sur- 
faces look somewhat toward the cheek. In these cases it is often 



T8 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

found that on opening the mouth the anterior border of the ramus 
of the lower jaw is carried forward, so as to impinge against the 
bow of the clamp. This difficulty may be overcome by using a 
clamp with a small bow and applying it in the following way: 
After carrying the clamp into the mouth, and before any attempt 
is made to place it over the tooth, the angle of the, lips on the 
side of the operation should be stretched well out and back with 
the fingers of the left hand, so as to expose the buccal surfaces of 
the upper molars to view; and then the patient should be instructed 
to close the mouth as far as possible. This will immediately throw 
the ramus back out of the way and further loosen the tension of 
the cheek and lips, so a better view is had and an adequate space 
left to slip the clamp to place. It will be found that in operating 
on these teeth there is little necessity for keeping the jaws very 
far apart, particularly if the operator is expert in the use of the 
mouth-mirror. All of the work on these teeth after the applica- 
tion of the dam should be performed through the reflection of the 
mirror, with the operator standing erect. By this method these 
cases are readily met and the difficulty overcome. 

In some instances on the lower jaw the ridge of bone extend- 
ing forward from the ramus is so prominent opposite the buccal 
surface of the third molar as to interfere with the application of 
an ordinary clamp, and in such a case the Southwick clamp, 
Fig. 32, is indicated. This clamp is made in four sizes, and 
should be in every operating case. It is often applicable to the 
upper teeth as well as the lower. 

-p „2 -Bad contacts between teeth, interfering 

most seriously with the adjustment of the 

J P' '-^ llM mi dam, are found in cases where slight decay 

iPlf loi /^5^ ^^^ commenced near the contact point, leav- 

1%, ^^ =s^^ ^^S sharp edges of enamel calculated to cut 

the dam, and also where there has been exten- 
sive wear of the teeth on the proximal surfaces from the individual 
movement of the teeth one against the other, resulting in broad 
contacts with the teeth tightly lodged together. Reference has 
already been made to the management of the f'^i-mer Avhereby a 



EXCLUSIOX OF MOISXrRE DURIXG OPERATIONS. 79 

thin broad-bladed instrument is forced between the teeth and the 
sharp edges of enamel broken down, but in many of the latter 
cases it is impracticable to force such an instrument between the 
teeth. This condition of worn facets on the proximal surfaces is 
often associated with teeth the occlusal surfaces of which have also 
been worn so that the teeth present a broad, flat, table-like surface 
on their occlusal aspect, joining at a sharp right angle the worn 
facet on the proximal surface. With teeth of this character pre- 
senting no V-shaped depression or slope from the occlusal surface 
to the contact point, as in normal cases, the problem of entering the 
rubber between the tee1;h is frequently difficult. In every such 
case the ligature should be passed between the contacts in advance 
of the rubber, to carry away any small particles of foreign material 
that may be lodged between the teeth. When the operator is 
certain that all the spaces are free the dam should be carried over 
the last tooth back with the clamp, and then the strip of rubber 
between that tooth and the one in front of it should be brought on 
a stretch over the contact points and held there with the fingers of 
the left hand, one finger forcing it down hard upon the buccal 
festoon of gum and the other upon the lingual festoon. While 
the dam is thus hung up over the junction of the two teeth, the 
right hand may be employed to slightly force the teeth apart by 
passing the end of a thin-bladed spatula in the interproximal space 
from the buccal or labial aspect, and prying on the teeth with a 
rotary movement of the spatula. This -will usually force the teeth 
apart sufficiently to allow the strip of rubber to glide between 
them, and the process may be continued from one contact point to 
another till all of the teeth are embraced by the dam. 

In every case of difficult contact the passage of the rubber may 
be facilitated by smearing the strips between the holes with vase- 
line or other suitable lubricant. This will allow it to glide more 
readily past the tight places, Itut care should be exercised not to 
allow any of it to come upon the surface of the dam to be grasped 
by the fingers. If by any inadvertence it gets on this surface it 
will instantly destroy all possibiKty of securing an adequate grasp, 



80 PKINCIPLES AND PRACTICE OF FILLING TEETH. 

and it is therefore well to dispense with it entirely except with 
teeth presenting particularly difficult contacts. 

Occasionally the operator will encounter trouble in applying the 
dam in cases where the teeth themselves are not at fault, on ac- 
count of muscular resistance on the part of the patient's lips and 
tongue. Where this tendency is discovered in any manipulation 
about the mouth it is sometimes advisable to hand the patient a. 
mirror and let him watch the movements of the tongue and lips, 
and see to what extent they are discommoding the operator. With 
some patients this is a sufficient appeal to their intelligence to 
result in overcoming the impulse, but with others there seems to 
be an uncontrollable tendency to resist the dam. In such cases, 
where it is impossible to bring about a relaxation of the muscles 
and an acquiescence on the part of the patient, the operator would 
better limit the application of the dam to as few teeth as will per- 
mit of reasonable access to the work. This difficulty is ordinarily 
confined more particularly to the lower molars, and it is usually 
advisable in such cases to let the application of the dam terminate 
at the first bicuspid. To keep the dam out of the operator's way 
and to hold it more secure against displacement from the action of 
the tongue and cheek, it is often a most excellent plan to slip a 
clamp over the first bicuspid with the bow looking toward the 
front of the mouth. A strong clamp should be used for the molar, 
and, after the rubber has been carried to place as best it may till 
the first bicuspid is reached, the bicuspid clamp should be taken 
up in the forceps with the jaws looking away from the forceps, and 
the clamp forced to position on the tooth. The dam is thus secured 
at either extremity of its application, and the operator's hands are 
free to use ligatures and carry the dam past the contact points and 
further perfect its adjustment. This method will often save the 
operator much annoyance in these stubborn cases. 

There are also certain cavities which, in mouths where for any 
reason the application of the dam is difficult, may be adequately 
protected by adjusting the dam to a single tooth. Small cavities 
in the occlusal surfaces of molars may often be filled in this way 
if the case presents peculiar obstacles to the extension of the dam 



ESCLUSIO:X OF MOISTURE DUKI^"G OPERATIONS. 81 

over other teeth. But the disadvantages of operating on a tooth 
under such conditions render it advisable to limit this practice to 
the fewest possible number of cases. 

The Use of Napkins and Cotton Rolls for Maintaining Dryness 
during Operations. 

In many minor operations, where the time necessary for their 
performance is quite limited, the rubber dam may well be dis- 
pensed with, and the teeth kept dry by the use of napkins or cotton 
rolls made for this purpose. The upper teeth are more easily man- 
aged in this manner than the lower ones, but even on the lower jaw 
the skillful use of the napkin may in many mouths serve a useful 
purpose. In employing napkins or rolls for the exclusion of 
moisture consideration should be had for the points at which the 
saliva enters the mouth, and an effort should be made to control 
it as far as possible at the location of its entrance. On the lower 
jaw the salivary ducts open into the floor of the mouth under the 
free end of the tongue, or just in front of the attachment of the 
tongue to the floor; while on the upper jaw the ducts open from 
the cheek opposite the buccal surfaces of the molar teeth. 

Napkins. 

Xapkins for this purpose are conveniently made from a piecf* 
of clean bleached linen, cut to the desired size and form for the 
case in hand, and after being used once should be thrown away. 
To exclude moisture from the lower teeth a piece should be cut 
sufficiently long to reach from the lingual surfaces of the molars 
on one side around under the tip of the tongue to the lingual sur- 
faces of the molars on the other. It should be wide enough so 
that when folded into a pad it will be sufficiently thick to fit with 
some pressure between the tongue and the lower jaw, but not so 
thick that the tongue is discommoded to the extent of rebelling 
against it and forcing it out of position. It will thus be seen that 
the size must vary in different mouths. 

To adjust this napkin it should be grasped with the pliers near 
one end, and the patient instructed to raise the tongue toward the 



82 PKINCIPLES AND PRACTICE OF FILLING TEETH. 

roof of the mouth. This end of the napkin should then be car- 
ried down between the side of the tongue and the lower jaw be- 
neath the lingual surfaces of the molar teeth on one side, and then 
the napkin passed under the tip of the tongue immediately over 
the salivary ducts and around to the other side of the mouth in the 
same way. The patient should then be instructed to allow the 
tongue to rest lightly on the napkin, but cautioned not to run it 
under the napkin and lift it. This protects the lingual aspect of 
the teeth, but the buccal surfaces require attention to guard against 
the saliva which flows down the cheek from Steno's duct. If the 
duct is located quite far up on the cheek it may be guarded by 
packing a short napkin between the cheek and the upper teeth, 
but if the opening is low the saliva is likely to trickle down along 
the cheek and reach the lower teeth. The only alternative is to 
place a plump napkin along the buccal surfaces of the lower molars 
and bicuspids, and hold it against the cheek and gum with the 
fingers. The saliva will of course flow down from the upper duct, 
but it will be absorbed by the thick napkin and not reach the 
lower teeth. If the napkin gets too much saturated, so as to 
endanger leaking against the teeth, it may be adroitly removed 
and replaced by a dry one. 

Dr. Geo. E. Hunt suggests a very effective method of employ- 
ing the napkin to secure dryness and control the tongue by pass- 
ing the napkin around under the tongue as just indicated and then 
carrying one end of it up across the dorsum of the tongue and 
with the fingers of the left hand tightly compressing the napkin 
and tongue down over the opening of the ducts. If held firmly 
the tongue, after a preliminary struggle or two, will remain quies- 
cent, and few patients will object to this procedure if it is done in 
a precise and determined manner. 

In most instances the compression of the napkin over the open- 
ings of the ducts will effectually stop all saliva from entering the 
m.outh, and under these conditions the napkin becomes adherent 
to the dried mucous membrane, and must be removed with the 
greatest caution through fear of injuring the membrane. 

In excluding moisture from the upper teeth with the napkin, it 



CLASSIFICATIOX AND PREPARATION OF CAVITIES. 83 

is necessary only to pack against the opening of Steno's duct by 
placing the napkin between the cheek and the upper jaw above 
and against the buccal surfaces of the molars and bicuspids. To 
prevent the patient from closing the mouth and moistening the 
cavity with the tongue, a mouth-mirror should invariably be held 
as a guard under the upper teeth in such a way as to protect the 
operation. 

Rolls. 

To provide a more convenient means than the use of the napkin, 
cotton rolls were devised and placed on the market. They are 
furnished by the manufacturers in various sizes, and in lengths 
sufficient to enable the operator to cut them to suit any individual 
case. They are effective for very short operations, — particularly 
upon the upper teeth, — but they have not the same range of ser- 
vice that has a napkin properly applied. It is seldom that they 
can be maintained in place if passed from the lingual surfaces of 
the molars on one side of the lower jaw to the molars on the other 
side, and their use is therefore practically limited to one side of 
the mouth. They are not so effective in guarding the orifices of 
the ducts as are napkins, and must depend chiefly upon their 
absorptive properties for gathering up the saliva as it flows against 
them. But they should be found in every operating case, on 
account of their great convenience in the limited number of cases 
to which they are suited. 



CHAPTER V. 

CLASSIFICATION AND PREPARATION OF CAVITIES. 

The following brief classification of cavities is adapted from the 
report of the Committee on Syllabus presented to the Institute of 
Dental Pedagogics, and adopted by that body. 

Cavities, as to character, are divided into two general classes: 
pit and fissure cavities, and smooth surface cavities. 

Pit and fissure cavities are those occurring as the result of 



84 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

structural imperfections in the enamel due to faulty development, 
whereby two or more islands of calcification in approaching each 
other have failed to grow together or coalesce, leaving a break in 
the continuity of the enamel-covering. This defect results in the 
admission of the micro-organisms of decay, and forms a harbored 
shelter in which they may work their destructive processes un- 
molested. 

These cavities are found in the occlusal surfaces of bicuspids 
and molars, in the lingual surfaces of upper incisors, and in the 
occlusal two-thirds of the buccal and lingual surfaces of molars. 
It will thus be seen that they occur in surfaces which are ordi- 
narily kept clean by the friction of food in mastication or by the 
tongue or cheeks, and are therefore directly traceable to faults in 
the enamel-structure. 

Smooth surface cavities are those occurring in surfaces where 
the enamel is perfectly formed, but where the location is such that 
it is not ordinarily kept clean by friction. They are thus dis- 
tinctive in character from pit and fissure cavities, both as regards 
the conditions which bring them about and the methods to be 
employed in their preparation. These distinctions will receive 
more detailed consideration later. 

Cavities under this head occur in the proximal surfaces, and in 
the gingival third of labial, buccal, or lingual surfaces. 

Cavities, as to extent and location, are divided into simple cavi- 
ties and complex cavities. 

Simple cavities are those involving only one surface of a tooth, 

as an "occlusal" cavity, a "buccal" cavity, a "labial" cavity, etc. 

Complex cavities are those involving two or more surfaces, as a 

"mesio-occlusal" cavity, a "disto-labial" cavity, a "mesio-disto- 

occlusal" cavity, etc. 

Cavities are named according to the surfaces of the teeth in 
which they occur, and cavity-walls are named according to the 
surface or anatomical landmark toward which they approach. 
Examples: In a mesio-occlusal cavity in an upper bicuspid the 
buccal wall is that wall which, if extended far enough, would 
involve the buccal surface of the tooth; the gingival is that wall 



CLASSIFICATION AND PREPARATION OF CAVITIES. 85 

which, if extended far enough, would involve the gingival line. 
In an occlusal cavity in a lower molar the bottom or floor of the 
cavity is called the pulpal wall, and in case of death of the pulp, 
so as to involve the pulp-chamber, the floor then becomes the sub- 
pulpal wall. 

An axial surface of a tooth is any surface parallel with the long 
axis of the tooth, and an axial wall is that wall which approaches 
the pulp in a cavity in an axial surface. 

CAVITY PREPARATION. 
Proximal Cavities in Incisors and Cuspids. 

Simple cavities not involving the incisal angle. — When decay 
occurs in the proximal surfaces of any of the anterior teeth, we 
are confronted with problems peculiar to the locality. The first 
consideration, as in every other class of cavities, is of course the 
preservation of the teeth, but in these exposed positions we must 
not ignore esthetic and artistic effects if we would do the highest 
class of service. Were it possible for us to save these teeth by 
filling without advertising the fact to the world, it would be our 
manifest duty to do so; but unfortunately this cannot always be 
done. It may also be stated that in the attempt to hide our work 
by confining our fillings to narrow areas we often jeopardize the 
teeth and lessen the confidence of the public in the permanence 
of dental operations through recurrence of decay and consequent 
undermining of the tooth-structure. 

Observant operators have noticed that there are certain points 
around ordinary proximal fillings where decay is most likely to 
recur. This relates in anterior teeth to the gingivo-labial, gingivo- 
lingual, and the incisal angles. The reason for this is found in the 
fact that these regions are not kept clean by the friction of food in 
mastication, or by the lips or tongue in their various movements. 
If the anatomical relation of the proximal surfaces of these teeth 
is studied, it will be seen that a considerable area in the vicinity of 
the contact point is not cleansed by the natural processes. This is 
what admits of caries in this region in the first instance. If in 



86 PRINCIPLES AND PRACTICE OF PILLING TEETH. 

the preparation of a cavity we liinit the area to a small round out- 
line, we have left unprotected, at the points indicated, more or 
less of the surface of enamel which is still subject to decay. With 
the same conditions present and the same influences at work which 
originally induced decay, there is little to prevent a recurrence. 
The remedy lies in so extending the outlines of the cavity that 
the margins are carried to a point where they will be kept clean. 
This process has been termed "extension for prevention" by Dr. 
G. V. Black, and its observance must be insisted upon where the 
most permanent work is required. 

Another point of frequent failure around these fillings is along 
the lingual margin. This is due to the fact that the lingual wall is 
often left exceedingly thin, and the enamel is crushed under the 
stress of mastication. The force of the lower incisors comes di- 
rectly against this surface, and any unprotected enamel is likely 
to be broken down. In every instance where possible the margin 
should be so extended as to leave the enamel well supported by 
dentine, and wherever this cannot be done the enamel should be 
freely beveled and the gold built over it in such a manner as to pro- 
tect it. Enamel protected in this way with care and skill will re- 
main intact in ordinary positions, and yet this does not alter the 
general rule that enamel is safest when supported by dentine. 

Fig. 33 shows the proximal surface of an incisor with a small 
round filling, a, points of recurrence of decay, hhh, and the outline 
to which the cavity should be carried for greatest safety, c. 

This question of extension is a matter calling for the most care- 
ful consideration. It is confidently believed to be a solution of the 
problem connected with a very frequent form of failure in this 
class of cases, and yet it must not be employed indiscriminately. 
There are many cases where it would be manifestly impossible and 
injudicious to cut the cavity to the extent indicated. Patients ap- 
ply to us for these fillings occasionally in such a nervous condition 
that any extra cutting beyond the present necessities of the case 
must be avoided. We should never jeopardiz;e the nervous system 
of our patient in order to carry out some heroic theory. Then, 
again, there are persons in whose mouths the tendency to caries 



CLASSIFICATION AND PREPARATION OF CAVITIES. 



87 



is SO slight that extension for prevention would appear to be an un- 
necessarily extreme measure. In some of these cases where there 
is limited decay, small fillings may prove serviceable for years. 
The age of the patient also has an important bearing on the ques- 
tion. Whenever we find the proximal surfaces breaking down 
rapidly under decay early in life, we may infer that the process of 
caries is to be active in that mouth, and we must employ the most 
strenuous means to control it. Extension for prevention is here 
indicated to its fullest legitimate extent. But in a patient well 
toward maturity with an occasional cavity developing, we may 
often safely stop short of the most extreme cutting. Then esthetic 
reasons play an important part in the anterior teeth. If we can 

Fig. 33. Fig. 34. Fig. 35. 






hide our fillings from view we should do so, and many of our 
patients are willing to take the chances of a recurrence of decay 
rather than have large fillings made in the first instance. A dis- 
tinct understanding should be had with patients upon these points, 
so that they may enter intelligently into the merits of the different 
methods. We should be sufficiently honest with them to proceed 
on the theory that wherever these small hidden fillings are inserted 
the work must be considered more or less temporary, and must be 
kept imder constant surveillance by the dentist. 

In brief, the operator's attitude toward the practice of extension 
should be to aim always at the most ideal and permanent form for 
his cavities, and in every instance where he deviates from this it 
must be only on account of some well-defined reason for doing so. 

There is one feature connected with the appearance of fillings in 
the anterior teeth which must not be overlooked. As has been 
said, it is sometimes well to keep fillings from view if possible, 
but whenever it becomes necessary for a filling to show at all it 
should be extended labially, so as to show distinctly. The reason 



"88, PKINCIPLES AND PKACTICE OF FILLING TEETH. 

for this is that where gold is placed between teeth in such a way 
that it is in the shadow, the appearance a few feet distant from the 
patient is that of a black mass simulating decay, while if the filling 
is carried out sufiiciently to allow the rays of light to reflect upon 
it the bright yellow tinge of gold is immediately perceptible. 
There should therefore be very little compromise between a filling 
kept entirely out of sight, and a good, bold showing of the gold 
from the labial aspect. Figs. 34 and 35 illustrate this point. 

Separating teeth. — The first requirement in operating on these 
cavities is to have sufficient space between the teeth for perfect 
access. This must be obtained in some instances by wedging pre- 
vious to the operation, in others space may be gained while oper- 
ating by the use of a separator. In cases where the teeth have 
fallen together to any appreciable extent as the result of deep 
proximal decay, or where the teeth overlap in a slight irregularity, 
the separator will ordinarily not gain sufficient space for a proper 
contour of the filling. ISTeither can we gain access to do perfect 
work on small, hidden cavities (in those cases where it may be 
deemed advisable to fill in that manner) short of extensive separa- 
tion. Where the labial or lingual wall is well cut away, the access 
is simplified. 

The methods employed for gradual separation previous to op- 
erating may be varied according to the requirements of the case. 
Rubber has been used for this purpose quite extensively in the 
past, but it is only in the rarest cases where rubber is properly 
indicated. The difficulty with this material lies in the fact that it 
cannot easily be maintained in position. The sloping surfaces of 
the teeth tend to make it slide away from the contact points 
and insinuate itself into the interproximal space to the serious 
injury of the gum-tissue. Rubber should never be used even in 
the extremest cases without previously protecting the gum by pack- 
ing cotton, gutta-percha, or cement against the gingival wall of the 
cavity, allowing it to extend across the interproximal space to pre- 
vent the movement of the rubber rootwise. 

The materials best adapted for separating are cotton, gutta- 
percha, and waxed linen tape. Cotton should be packed firmly be- 



CLASSIFICATION AND PREPARATION OF CAVITIES. • 89 

tween the teeth while dry, and if there is difficulty in maintaining 
it in position it can be secured by passing a ligature between thd 
teeth in the interproximal space before placing the cotton, and 
then bringing the ends down over it toward the incisal surfaces of 
the teeth and tying tightly around the cotton. This holds it 
securely in place and proves a very effective means of separating 
teeth. Fig. 36 illustrates the method of tying the cotton in place. 

Gutta-percha may be employed by first adjusting the separator, 
forcing the teeth slightly apart, and packing the gutta-percha into 
the cavity and firmly between the teeth. The separator is then 
removed and the gutta-percha allowed to remain for several days. 
This will usually result in good space without soreness. 

AVaxed linen tape of a suitable width for the case in hand may 
profitably be employed in those cases where there has been little or 
no breaking do"\vn of the proximal surfaces, and where it would 
be difficult to retain cotton or gutta-percha. By either of' these 
methods the pressure is so gradual that space is gained without 
the distressing irritation which usually accompanies the use of 
rubber. 

In favorable instances, or in emergency cases, space may be 
gained at the time of the operation by the use of the separator. 
"Wherever the separator is indicated it should be used in the fol- 
lovsdng way : Care must be exercised in its adjustment not to allow 
it to impinge on the gum or unnecessarily wound the soft tissues. 
It should not be tightened to the limit at once, but merely 
"snugged up" till the patient feels it. Then, as the operation 
progresses, it can be gradually tightened at intervals without 
appreciable discomfort. By the time the cavity is prepared, suf- 
ficient space will usually have been gained to admit of the inser- 
tion and proper contouring of the filling, and then a slightly addi- 
tional space obtained during this part of the operation will afford 
opportunity for polishing. When the filling is finished, the great- 
est caution should be observed in removing the separator. If it is 
loosened suddenly after being tightened to the extent usually neces- 
sary, it will result in most excruciating pain to the patient, the 
discomfort from this source ordinarily being greater than from the 



90 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

process of separating. It should be loosened very gently and 
slowly till the contact between the filling and the tooth next in 
line is sufficient to hold the teeth from further movement. 

In manipulating the separator the greatest delicacy of touch 
should at all times be exercised. It is a dangerous and cruel ap- 
pliance in the hands of the thoughtless or careless. The operator 
should invariably employ one hand to steady the bows while the 
other tightens the screws, to prevent tilting or shifting the sepa- 
rator. Any rocking or twisting of the appliance will result in un- 
necessary pain, and undue injury to the soft parts. Another seri- 
ous limitation to the separator lies in the danger to enamel-margins 

Fig. 37. Fio. 38. 

6 




when the jaws impinge close to the cavity. The enamel may 
thereby be checked in such a way as to jeopardize the usefulness of 
the filling without the operator's observation of the fact at the time. 
Cases for the separator should be selected with care and judgment, 
and due consideration for the patient must invariably accompany 
its use. With these precautions, it is really a humane appliance 
and is capable of a large range of usefulness. It is not only indi- 
cated for gaining space between teeth, but may frequently be used, 
where space has already been obtained, for the purpose of holding 
the teeth firm during the operation. This avoids in large measure 
any soreness from malleting, and also prevents the teeth from grad- 
ually dropping together while the filling is being inserted. 

Wooden wedges may also be used occasionally for this purpose, 
but the difficulty with wooden wedges lies in the fact that they are 
usually injurious to the gum-tissue in the interproximal space, and 
their entire wedging force must be exerted immediately instead of 
gradually. Whenever a wooden wedge is used to hold the teeth 
firm during an operation it should be made as narrow as possible, 
and the rubber dam should be stretched well labiallv before the 



CLASSIFICATION AND PREPARATION OF CAVITIES. 91 

wedge is inserted, to overcome the tendency which the dam other- 
wise w'onld have of dragging the wedge out of place. Dr. George 
E. Hunt suggests as an expedient to prevent the rubber from snap> 
ping the wedge out of place to take a thin shaving made in whit- 
tling the wedge, and with the pliers slip it into the interproximal 
space with its side against the rubber, using this as a guard for the 
wedge. 

Detail of Cavity Formation. 

After frail enamel-walls have been broken down and the mar- 
gins extended to the desired outline, all decay should be removed 
and the cavity given such form that the filling will be retained 
securely in place. 

The gingival ivall. This wall should be extended rootwise suf- 
ficiently to carry the margin of the filling well under the gum in 
accordance with Fig. 33. The line d represents the gum as it 
comes down between the teeth in the interproximal space, and the 
outline of the filling c shows the gingival portion overlapped by the 
gum. The reason for this extension is the well-known fact that 
wherever we have the gingival portion of a perfectly inserted fill- 
ing covered by healthy gum-tissue, we will never have recurrence 
of decay at that point. In cases where the enamel has begun to 
take on a whitened appearance at the gum-margin extending 
gingivo-labially and gingivo-lingually from the cavity, thus in- 
dicating an approaching disintegration, or where the activity of 
the carious process seems to be very great in that mouth, the gingi- 
val outline of the cavity should be carried well out gingivo-labially 
and gingivo-lingually as illustrated in Fig. 37. This gives the 
gingival outline a curve with its convexity toward the cavity. 

The gingival margin of proximal fillings has often been alluded 
to as the "vulnerable point," even when fillings were well inserted, 
but this is hardly in strict accordance with facts. In reality decay 
seldom recurs along the gingival margin proper. It usually begins 
at the gingivo-labial (or buccal) and gingivo-lingual angles. From 
here it may extend and involve the entire gingival margin, but the 
initial point of failure is usually at the angles. This is because 



92 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

there is a lodgment-place in these positions for deleterious matter 
to form "undisturbed by friction from the tongue or lips, and un- 
protected by gum-tissue. In this small sheltered harbor the micro- 
organisms of caries produce their acid and attack the enamel, l^o 
tooth may be considered safe from recurrence of decay around 
proximal fillings unless the gingival wall has been carried suffi- 
ciently rootwise to bring that portion of the filling under the gum, 
and the gingivo-labial and gingivo-lingual angles have been ex- 
tended to a point where these margins of the filling are kept clean 
by friction. 

This form of extension results in the gingival wall being either 
flat labio-lingually or convex toward the cavity, and this is be- 
lieved to be desirable for other reasons than those of prevention. 
A filling is more easily built upon a flat base than upon a curved 
base, and is more secure from dislodgment when completed. The 
prevailing custom of forming the gingival wall on a curve labio- 
lingually so as to be concave toward the cavity is accountable 
for the fact that many operators find their fillings rocking when 
partly inserted, and it has also led to the necessity of drilling pits 
more or less deep (and more or less disastrous) in the gingival 
portion of the cavity. 

To subserve the best ends in anchorage the gingival wall should 
also be made flat mesio-distally, with a slight incline rootwise as 
the gingival wall approaches the axial wall. In some instances this 
incline may take the form of a shallow groove in the dentine ex- 
tending from the gingivo-labial to the gingivo-lingual angles of the 
cavity, and carried somewhat into the lingual wall at this point to 
facilitate the starting of the filling. It should not be carried to any 
extent into the labial wall, on account of the difficulty of adapting 
gold into an inaccessible undercut such as this would be. 

The lingual ivall. As has already been intimated, this wall 
should be freely cut away if frail. The temptation to leave it for 
the purpose of having something to build the gold against in the 
insertion of the filling has proved the stumbling-block of many an 
operator. If sufficiently supported by dentine it need not be ex- 
tended farther than is necessary for prevention, but in some in- 



CLASSIFICATION AND PREPARATION OF CAVITIES. 93 

Stances it must be cut away nearly on a line with the axial wall. 
Especially is this true in those cases where for esthetic reasons 
it is considered desirable to leave the labial wall standing and insert 
the filling mostly from the lingual aspect. The difficulty of doing 
a perfect and permanent operation in this way renders these cases 
rare, and limits them sharply to cavities having a strong labial 
wall. 

When the lingual wrfU is cut away freely, the only attempt at 
retention along this wall should be as it approaches the gingivo- 
axial angle and the incisal angle. Here a right angle may be made 
with the axial wall, or in the gingival extremity of the lingual wall 
the groove previously mentioned in the gingival wall may be di- 
verted at right angles into the gingival third of the lingual wall. 
This not only aids in retention, but provides a cul-de-sac into which 
may readily be secured the first pieces of gold. Deep grooving 
should generally be avoided in these cavities on account of the 
uncertainty of gaining perfect adaptation and density of the gold 
in the bottom of grooves, and also because of the consequent weak 
walls to the cavity; but in the gingivo-lingual region these ob- 
jections are not strictly operative. Direct access may be gained 
with a plugger, and the bulk of tooth-tissue covering the pulp 
at this point admits of judicious grooving without creating weak 
walls. But in no instance, even where it is deemed advisable to 
leave the lingual wall standing, should the groove be extended 
throughout the length of the wall. The most that should be done 
in the middle third of the wall is to make more or less of an angle 
between that and the axial wall. 

The labial wall. The same general rules apply to the formation 
of this wall that have just been outlined for the lingual wall, except 
that grooving is contraindicated in any portion of its length. In 
cases where possible an angle may be formed with the axial wall 
to increase the security of anchorage, and especially should this be 
done in the gingival and incisal thirds. 

The incisal angle. This should be formed at right angles with 
the axial wall. It should never be deeply grooved, nor should a 
pit be drilled at this point, as is frequently done. To assist in re- 



94 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

tention of the filling it may be slightly inclined toward the incisal 
edge of the tooth as it approaches the axial wall. 

The axial wall. The form of the other walls practically deter- 
mines the shape of this wall. It should be as nearly as possible at 
right angles with the others, leaving in all cases as much dentine 
covering the pnlp as is consistent with strength of the filling and 
a thorough removal of all decay. 

The enatnel-margins. The final step in the preparation of the 
cavity is the treatment of the margins. The enamel should be so 
beveled that the peripheral ends of the rods are cut off and the den- 
tinal ends covered with gold when the filling is inserted. This 
calls to mind the necessity for introducing two terms to properly 
designate enamel-margins. In reality there are two margins to 
enamel, and in cavities such as we are considering a clear distinc- 
tion between the two is important. There is the enamel-margin 
at the periphery of the tooth, and the enamel-margin next to the 
dentine. Eor want of better terms these may be designated the 
peripheral enamel-margin, and the dentinal enamel-margin (Fig. 
38, aand&). 

If in all cases the enamel could be left well supported for con- 
siderable depth by dentine the distinction in terms would not seem 
so important, but this is not always possible ; and where such is the 
case the treatment of these two margins is dissimilar. The periph- 
eral margin should be given a distinct bevel, while the dentinal 
margin should be slightly rounded. 

The necessity for beveling enamel relates to the peculiarity of 
its structure. It is composed of rods standing with their ends on 
the dentine and radiating out toward the periphery of the tooth in 
a more or less regular manner. The enamel when supported by 
dentine, and with no break in the continuity of its structure, will 
sustain great stress without fracture, but when undermined by 
decay it is easily broken down. This break is usually in line with 
the enamel-rods, which indicates that the cement-substance holding 
the rods together is not very strong. If, then, the peripheral ends 
of the rods are left standing around a filling while the dentine is 
gone, and possibly the dentinal ends of the rods dissolved out by 



CLASSIFICATION AND PREPARATION OF CAVITIES. 95 

caries or burred away in the preparation of the cavity, it is readily 
seen that the short peripheral rods must sooner or later drop out, 
even if they escape crushing in the insertion of the gold. This 
admits of a leak around the filling. To make perfect margins the 
enamel should be so beveled that there are no short rods at the 
periphery. But this bevel must not be too acute, nor must the 
peripheral margin be rounded. Either of these conditions would 
result in the filling-material assuming too attenuated a form at the 
edges, which would admit an element of weakness to the filling. 
The exact degree of bevel cannot well be given in figures, owing 
to the variation necessary in the different locations along cavity- 
margins on account of the varying direction of the enamel-rods. 
The degree of bevel must largely be governed by the direction of 
the rods in each particular locality, and the only way to determine 
this short of a microscopical examination, which, of course, is im- 
practicable in the mouth, is by the sense of touch. The operator's 
fingers may be so schooled that in trimming the enamel with a 
sharp chisel he can readily determine the arrangement of the rods 
by the ease with which the enamel is cleaved in certain directions. 
Remembering that the enamel cleaves most readily in line with the 
direction of the rods, he is able to intelligently judge the condition 
of the margin by the manner in which the blade affects it, and 
so long as the peripheral portion of the enamel breaks down readily, 
or is easily pulverized, the trimming must continue. This delicate 
"feeling" along the margins of cavities with a sharp instrument is 
very necessary to the establishment of a perfect outline, and is the 
only true criterion as to the degree of bevel indicated in each given 
case. 

In every instance where the dentinal enamel-margin is at all 
prominent it should be slightly rounded, as already indicated, to 
facilitate the perfect adaptation of the gold against it. (Fig. 39, a, 
peripheral enamel-margin beveled, h dentinal enamel-margin 
rounded, c filling-material protecting margin.) 

The marginal outlines of these cavities should represent sym- 
metrical and graceful curves that will not offend the eye of the 
artist. In the formation of the walls of the cavity, angles have 



96 PKINCIPLES ANT) PRACTICE OF FILLING TEETH. 

been recommended at various points for the firm retention of the 
filling, but angles are never permissible along the margins for 
esthetic reasons. As the gingival margin joins the labial or lingual 
margin it should not be at a sharp angle, but on a curve. This 
curve may in some instances be rather short, but it must invariably 
be a symmetrical and definite curve. The outlines along the labial 
and lingual walls should be true and clearly cut to present the most 
artistic appearance. The dentist should aim not only to do ser- 
viceable operations, but to do beautiful ones as well. 

Technique. — The first step in the operation is to break down un- 
supported enamel-margins. This may best be done with suitably 
formed chisels, made sharp. In some instances the thin overhang- 
ing labial wall may be cleaved away to advantage with a short, 
strong hatchet excavator. The blade must not be long enough to 
penetrate into the cavity sufficiently to expose the pulp or impinge 
on sensitive dentine as the enamel is broken in. Care should be 
exercised especially in the early stages of the operation not to 
shock the patient. A false movement at this time will do much 
to unnerve the average individual. If it is found necessary to give 
pain in an operation, it is best if possible to defer that particular 
part of the work till the patient has been some minutes in the chair. 
It will ordinarily then be better tolerated. 

After weak walls are broken down the cavity should be extended 
to its proper outlines. This can usually be done rapidly and effect- 
ively with sharp burs, either round or oval as the case demands. 
In the use of burs for this purpose — or in fact for any purpose — 
due regard must be exercised for maintaining the bur precisely at 
the angle and in the position required. 'No operator should ven- 
ture to use an instrument like the dental engine without previously 
having acquired an absolute control of the hand-piece, and having 
studied carefully its dangers and limitations as well as its legiti- 
mate uses. The failure of operators to properly manipulate the 
engine is accountable for much of the prejudice against it. The 
principal dangers to be guarded against in extending these proxi- 
mal cavities in incisors relate to the displacement of the bur by 
catching the blades against the margins of enamel and carrying the 



CLASSIFICATION AND PKEPAEATION OF CAVITIES. 97 

bur either into the cavity or out across the surface of enamel. To 
prevent this the hand-piece should be firmly grasped and the bur 
applied to the margin mthout too much force, and at such an angle 
that it may be maintained in position. 

If the cavity is one which looks toward the operator, the bur may 
be held at right angles with the long axis of the tooth, and in that 
position it is not likely to slip. In cavities looking away from the 
operator where the position of the bur is more nearly parallel with 
the long axis of the tooth, the shank of the bur should have a bear- 
ing on the surface of the enamel in such a way that the bur will be 
braced against the displacement while the blades are playing along 
the margins. 

Fig. 39. Fig. 40. 



feti' 




After the cavity has been extended to the desired outlines the 
decalcified dentine should be removed. This is ordinarily best 
done with thin, sharp excavators, though in some instances the 
same bur which extended the outlines may be used for a few revo- 
lutions to remove the diseased tissue. In those cases Avhere the 
decay has penetrated to any extent, this work should be done with 
spoon excavators to avoid needless pulp-exposure. An instrument 
with a sharp angle, as in the hatchets and hoes, is more likely to 
penetrate too far and puncture the pulp than one with a rounded 
form such as the spoons. 

When the carious tissue is removed the walls should be shaped 
for anchorage. For the gingival wall an inverted cone bur of suita- 
ble size should be placed with its end against this wall, and the 
shank as nearly as may be parallel with the long axis of the tooth. 
It is then carried labially and lingually along the gingival wall till 
the proper form is secured. The end of the bur leaves the gingival 
wall flat, and produces nearly a right angle between the gingival 
and axial walls. This angle, while not strictly speaking a right 
angle (unless the bur is held perfectly parallel with the tooth), is 

7 



98 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

sufficiently so for practical purposes, and the form left by the bur 
presents a surface parallel with the end of the plugger point, thus 
facilitating the adaptation of the gold against this wall. In cases 
where necessary the gingival wall may be slightly grooved with the 
bur, but in every instance it must be used with care and judgment 
to avoid too deep cutting and pulp-exposure. 

As the bur reaches the gingivo-linguo-axial angle of the cavity 
it may be withdrawn crownwise along the gingival third of the 
lingual wall, making a slight groove at this point as before advo- 
cated. This groove formed by the side of the bur will be rounded. 
If deemed advisable it may be squared out with an excavator to an 
angle with the axial wall. 

The labial wall is formed by placing the inverted cone bur with 
its end against the axial wall and its shank at right angles with the 
long axis of the tooth. By carrying the bur laterally along the 
labial wall from the gingival wall to the incisal angle the side of the 
bur will give form to the labial wall, and an angle will be created 
between that and the axial wall. 

The incisal angle of the cavity may be formed, in cases where 
there is suitable access, by carrying the inverted cone bur down 
into this angle, cutting sidewise, with its end facing the axial wall. 
The form of the bur gives the required angle between the incisal 
and axial walls. Where the bur cannot be placed in the proper 
position to accomplish this purpose, the incisal angle may be 
formed with small, delicate excavators, and in the entire formation 
of the cavity indications may point to the use of excavators instead 
of burs. It is believed that with sharp burs carried in a hand-piece 
under perfect control more effective cutting can be made in a given 
time than with hand instruments, and yet the operator must not 
lose sight of the advantages of excavators under certain conditions, 
nor enslave himself to the prejudiced following of any one method 
under all circumstances. He should study the mechanical and the 
nervous requirements of the case, and readily adapt himself to the 
most serviceable plan of procedure. 

The enamel margins may be beveled with a fine-bladed round 



CLASSIFICATION AKD PREPARATION OF CAVITIES. 99 

bur used in the manner advocated for cavity extension, or they 
may be phined off with delicate sharp chisels, as the case indicates. 

General Considerations. 

It may be noted that some of the suggestions here advanced 
relative to cavity formation appear somewhat radical when com- 
pared with the methods generally in vogue in the profession. 
The advocacy of angles between the walls of these cavities may 
impress many as being illogical and impracticable in view of the 
orthodox teaching on the subject. Curved outlines to cavity-walls 
have usually been suggested whenever there has been any sugges- 
tion at all. This has been done with a view of making a cavity 
into which the filling-material might easily be adapted, and one of 
the first objections likely to be urged against the formation of 
angles is the supposed difficulty of adapting gold into such angles. 
This question of the non-adaptability of gold to angles has been 
much overdrawn. It is simply a matter of proper manipulation, 
with pluggers of a suitable form to carry the gold into the angle. 
It need not here be stated that a plugger with a round shank and a 
flat serrated face is not the form for this purpose. 

Gold can easily and accurately be adapted into a sharp right 
angle, as has repeatedly been proved by experiment. The advan- 
tages of making angles in cavities relate to the ease with which 
fillings may be started in such cavities, and the unquestioned 
security of anchorage without undermining and weakening the 
walls. Fillings built upon flat bases have a greater stability against 
displacement under stress than those built upon curved bases, and 
the gold is less likely to rock during its insertion. 

It will be found that in the practical application in the mouth of 
the methods here advocated it is seldom that a perfectly sharp 
angle is made in one of thevse caviti&s, especially in any position 
where it is at all difficult to fill. The principle involved is merely 
the formation of flat walls instead of curved walls, and the operator 
who makes the trial of building fillings against flat walls after being 
accustomed to curved walls will not long remain in doubt as to 
which is the profc'ral)lo method. There is a sense of security to 



100 PRINCIPLES AND PRACTICE OF PILLING TEETH. 

the work as it progresses which is never experienced when the 
walls have been formed in curves. 

Fig. 40 shows a longitudinal section of a tooth mesio-distally, 
with cavitj formed and filled. It will be seen that the filling is 
mortised or dovetailed into place, with no deep grooves or under- 
cuts to weaken the walls. 

Proximal Cavities in Anterior Teeth Involving the Incisal Angle. 

When caries has progressed so far that the proximo-incisal 
angle is either broken down or so undermined that it is unsafe to 
leave it, the problem of anchorage becomes correspondingly com- 
plicated. With this angle gone and the consequent necessity for 
its reproduction in gold, an additional area of filling is exposed to 
stress tending to its dislodgment. The usual plan of anchoring 
these fillings has been to groove the gingival wall deeply, with addi- 
tional grooves along the labial and lingual walls wherever pos- 
sible, and then drill for anchorage in the incisal region between 
the lingual and labial plates of enamel as they approach each other 
near the incisal edge. (Fig. 41.) 

While many fillings anchored in this manner have stood the test 
for years, and while there are some instances in which this is the 
only practical method of anchorage, it is confidently believed that 
for the majority of cases there is a better and safer means at hand. 
The limitations of this method relate to the fact that any tipping 
stress upon such a filling has a tendency to lift it away from its 
incisal anchorage, and either loosen it entirely, or so dislodge it as 
to cause a leak along the incisal half of its outline. (Fig. 42.) 

To more securely anchor these fillings at their incisal extremi- 
ties, it is recommended to create a step at right angles with the 
main body of the filling by cutting a groove along the incisal edge, 
or rather by cutting away the incisal portion of the lingual plate of 
enamel to a sufiicient depth and length to gain strength of filling- 
material. The labial plate of enamel is ordinarily left standing 
for appearance, so that while more gold is used in this kind of a 
filling, the excess is presented to the lingual aspect of the tooth. 
Fig. 43, and there is no greater exposure of gold to the labial aspect 



CLASSIFICATION AND PREPARATION OF CAVITIES. 101 

than in the ordinary contour filling. The advantage of this form 
of anchorage mnst appeal to every mechanical mind. A filling 
properly placed in such a cavity cannot be dislodged short of frac- 
ture of the filling or stretching of the gold from repeated impacts 
of the lower tooth at the point where the main body of the filling 
joins the step. Stress brought to bear on such a filling in the 
process of biting has a tendency to force the filling into the cavity 
instead of lifting it away, as in the usual methods of anchorage. 

Detail of Cavity Formation. 

The same general plan of formation is followed in the gingival 
third of the cavity that was advocated for simple proximal cavi- 
ties, except that the anchorages may be made deeper, and if pos- 
sible broader, for the contour filling. 

The labial wall. This wall should be fonned as nearly as possi- 
ble at definite right angles with the axial wall. The creation of an 
angle at this point is a matter of importance in all cases where the 

Fig. 41. Fig. 42. Fig. 43. Fig. 44. Fig. 45. Fig. 46. 




extent of the labial wall will permit it. The direction of stress 
against these fillings by the lower incisors is often obliquely up- 
ward and toward the labial (Fig. 44), and the broader we can make 
the area of resistance to this stress the more securely will we retain 
the filling. The open aspect of these cavities renders the adapta- 
tion of gold into such an angle very convenient. The labial wall 
of the step should have the same form and same angle between it 
and the seat of the step or pulpal wall. This portion of the labial 
wall should be left as thick as possible to prevent the gold from 
showing through and to represent considerable strength. In those 



102 PRIIICIPLES AND PKACTICE OF FILLING TEETH. 

teeth where the incisal edge is so thin that there is no opportunity 
for leaving an adequate labial plate it may be necessary to shorten 
the labial wall somewhat and build the gold over it so as to expose 
it to view from the labial aspect. (Fig. 45.) In such a pro- 
cedure artistic appearance is sacrificed for safety. 

In every instance where this wall is left standing, it should be 
beveled as illustrated in Fig. 46, and the gold built over the bevel 
with the greatest care. Protected in this way, it is often possible 
to retain this wall with safety, and thus disguise our operation to 
that extent. 

In considering the strength of this wall an objection may be 
urged by some against the formation of an angle to the cavity at 
the junction of the labial with the other walls, on the mechanical 
ground that whenever a fracture occurs it is more likely to locate 
itself at an angle than at any other place. In view of the fact that 
the present system of cavity preparation involves the formation of 
angles at different points in the depths of cavities, it may be well to 
consider this matter at this time. 

If we stop to study the causes of fractured walls, we shall see 
that they are due either to the fact that the walls have been left 
unprotected by gold, or that the gold has so shifted from its orig- 
inal position in the cavity as to bring undue stress upon the wall. 
If we protect the wall with gold and the gold remains firm, there 
will be no fracture. The question arises how to maintain the gold 
secure against movement. According to the most approved and 
logical mechanical principles, this is best solved by building it 
against flat walls joined by angles, rather than against circular 
walls joined by curves. Other things being equal, gold will shift 
under stress just in proportion as the base upon which it rests is 
rounded. It is simply the difference between attempting to roll 
a cube and a sphere. 

But aside from this, those who have been led to fear fractured 
walls on account of making angles in cavities need not hesitate 
on this score, because in the mouth it will be found practically im- 
possible to form an angle so sharp or so acute that it will determine 
the location of a fracture, — even if a fracture should occur. The 



CLASSIFICATION AND PREPARATION OF CAVITIES. 103 

attempt to make angles insures more fully the general plan of flat 
surfaces, and is recommended mainly for that purpose. It is 
firmly believed that the ideal cavity should have flat walls joined 
by definite angles, forming a mortise for the filling-material, but it 
is exceedingly difiicult to attain the ideal in the mouth. 

As has already been stated, these angles should be confined to 
the interior of the cavity, and when the exposed outlines are 
formed they should be given symmetrical curves for esthetic rea- 
sons. In accord with this the margin of the labial wall of the 
cavities under consideration should execute a short curve from the 
proximal to the incisal rather than have an abrupt angle at that 
point. (Fig. 47.) 

The Ungual ivall. This wall should be cut freely away in the 
incisal region to admit of sufiicient bulk of gold to represent con- 
siderable strength to the filling as the proximal joins the incisal 
portion. This is essentially the weak point of these fillings, any 
breaking or stretching of the gold resulting in a lifting away of the 
proximal portion of the filling. 

This wall should be given some retentive form to maintain the 
filling against possible force from the labial aspect in the form of 
accidental blows. This can usually be accomplished in the gingi- 
val third of the Avail and at the extremity of the step if no other 
opportunity presents itself. (Fig. 43, a, h.) 

The step. The length of the step mesio-distally must be deter- 
mined by the requirements of the case. It should be extended far 
enough to firmly anchor the filling, and in those cases where the 
incisal edge of the enamel has been worn down so as to expose the 
dentine the step should be carried across the tooth to include all 
exposed dentine. It should be made sufficiently deep pulpally to 
admit of strength to the gold, but not far enough to endanger the 
pulp. Its width labio-lingually must be governed somewhat by 
the thickness of the tooth, and in those cases where necessary the 
lingual plate may be cut away freely to add to the width of the 
step. 

The base of the step, or pulpal wall, should be made perfectly 
flat. This is one of the most important considerations in the kind 



104 



PKINCIPLES AND PBAOTICE OF FILLING TEETH. 



of cavity formation under discussion. If the pulpal wall is rounded 
in the least degree, it materially lessens the stability of the mesial 
portion of the filling. The limited area presented for the re- 
ception of the gold at this point imposes upon us the necessity for 
maintaining the greatest possible security to a given bulk of ma- 
terial, and this can only be done by building the gold against 
a perfectly flat surface. This wall should also be extended slightly 
into the dentine pulpally as it approaches the termination of the 
step. (Fig. 43, a.) This is to add to the security of the filling 
against the tipping stress. As the step terminates, it should end in 
an abrupt wall parallel with the long axis of the tooth and at a 
right angle with the pulpal wall. 



Fig. 47. Fio. 48. 



Fig. 49. 



Fig. 50. 






Technique. — The same general plan of technique may be fol- 
lowed as was advocated for simple proximal cavities up to the for- 
mation of the step. To form the step an inverted cone bur should 
be placed with its side against the incisal third of the axial wall, as 
illustrated in Fig. 48, and carried laterally into the tissue to the 
extent required for the length of the step, — the cutting being done 
with the side of the bur. This leaves the desired flat base to the 
step. The projecting lingual plate of enamel left by the bur can 
readily be broken down with chisels. 

The labial and lingual enamel-margins can best be beveled with 
small sand-paper disks in the engine, provided the operator studies 
carefully their proper use. The disk must be held at such an angle 
as to give a distinct bevel. Any rocking or tipping of the disk will 
result in a rounding of the peripheral enamel-margin, the disad- 
vantage of which has already been mentioned. The enamel at 
the termination of the step can be beveled with a round bur. 



CLASSIFICATIOISr AND PREPAKATION OF CAVITIES. 105 

General Considerations. 

Two items of detail must be carefully observed to make this 
method of cavity preparation of the highest esthetic value. The 
labial wall must be left as thick as possible to avoid the reflection of 
the gold through the enamel, and the gold must be adapted accu- 
rately to this wall throughout. If there is any failure of perfect 
adaptation, the filling will eventually leak at this point, giving rise 
to an unsightly discoloration under the enamel. The most delicate 
and precise placing of the gold and the highest degree of density 
possible are necessary for perfect results. When these are at- 
tained, it is confidently believed that this method will prove very 
serviceable in a certain class of cases which have in the past been 
troublesome to many operators. 

The contraindications to this method relate to cases where the 
lingual wall has been extensively disintegrated by caries, thus de- 
stroying the possibility of making a step anchorage. Usually such 
cases involve the pulp, and wherever the pulp is removed, an- 
chorage may be obtained if necessary by cementing a strong iridio- 
platinum post into the pulp-chamber and allowing it to extend 
toward the incisal portion of the cavity in such a manner that the 
gold can be built around it and the filling retained in position. 
(Fig. 49.) No one method is universally applicable to these cases 
any more than to other cavities, and the operator who would at- 
tain the best results must carefully study each case that presents 
and be prepared to apply the particular method indicated in. 
that especial case. The most that can be taught are principles 
and plans, and he who cannot apply his individual ingenuity to 
meet the requirements of special cases ought never to have been a 
dentist. 

The question may arise with some as to the advisability of in- 
serting these large contour fillings. instead of crowning the teeth; 
in fact, we see occasional doubts thrown upon contour operations 
since crown-work has become so common. It must always remain 
a matter of the nicest discrimination just when to abandon filling 
and substitute crowning, but it may be laid down as a safe axiom 
that a tooth presenting sufficient material to maintain a filling for a 



106 PiaNCIPLES AND PKACTICE OF FILLING TEETH. 

reasonable period should be filled. Sometimes these extensive 
operations will last many years, and when the final crash comes 
and the filling is lost, the tooth presents the same opportunities for 
crowning that it did before it was filled. Crown-work has not yet 
been sufficiently long in use to determine definitely its perma- 
nence, and until we have had a more prolonged experience it may 
be safe to assume that in filling a doubtful tooth we extend the 
serviceability of that tooth just the number of years the filling lasts. 
In other words, the crown is likely to remain in service as many 
years after the filling has failed as it would have done had it been 
employed in the first instance. It is therefore sometimes advisable 
to fill these incisors, even when both mesial and distal incisal 
angles are gone, and to produce a filling such as is illustrated in 
Fig. 50, a, labial aspect, &, lingual aspect. 

The objections often urged against these extensive fillings on 
the ground of their excessive weariness and nervous tax to the 
patient are rapidly being discounted by modern methods of oper- 
ating, and the dental chair of to-day need not be the rack of torture 
that it sometimes in the past has been accounted. Filling opera- 
tions by virtue of improved technique and systematic plans of pro- 
cedure have been shortened nearly one-half over former days. 

Proximal Cavities in Bicuspids and Molars. 

The principles involved in the treatment of caries occurring in 
the proximal surfaces of bicuspids are so similar to those occur- 
ring in like surfaces of molars that they will be considered as one 
class of cavities. Minor differences in the detail of the work will, 
it is true, be called for, but these are readily suggested by the 
differences in the forms of the teeth. The position and function 
of bicuspids and molars are nearly identical, and they are subject 
to practically the same influences leading to decay primarily and 
to a recurrence of decay around fillings. The same forces are at 
work to dislodge fillings, and the same general plan of anchorage 
must be pursued in the one as in the other. For these reasons 
they are treated in common. 



CLASSIFICATION AND PREPARATION OF CAVITIES. 107 

Simple Proximal Cavities not Involving Other Surfaces, 

The instances are very rare where it may be deemed advisable 
to fill this kind of a cavity. Usually when decay begins on the 
proximal sin-face of a bicuspid or molar, the proper preparation 
of the cavity involves its extension through to the occlusal surface. 
Almost the only exceptions relate to those cases where the cavity 
faces an open space caused by the loss of a tooth, or to those occa- 
sional instances where there has been extensive recession of the 
gums in the interproximal space and consequent decay in the 
gingival region. This latter usually occurs in advanced age, when 
such extensive cutting as would be necessary to involve the oc- 
clusal surface would not be justifiable, and where the open inter- 
proximal space admits of access from the buccal aspect. The 
farther rootwise the decay occurs the stronger the argument for 
filling without extending occlusally, on account of the better 
facility for approach and the greater thickness of the occlusal wall. 

But in ordinary caries occurring near the contact point, and 
with the teeth standing in line one against the other, the rule 
should be to open the cavity to the occlusal surface. The reasons 
for this lie in the fact that in such cases access cannot be gained to 
do perfect work short of very extensive separation, and then when 
the teeth have been so separated and filled, and have fallen back 
to their original position, an element of danger to the filling re- 
mains on account of the margin of the filling being too near the 
contact point. The reason that decay begins in this locality in the 
first instance is because a certain area of the tooth-substance is left 
exposed to the action of micro-organisms, undisturbed by friction 
of the tongue, cheeks, the tooth-brush, or of food in the process of 
mastication. If the line between enamel and filling be left near 
the contact point, the same influences which induced the original 
decay may be expected to act on the enamel at the margin of the 
filling to bring about a recurrence. If the cavity is extended oc- 
clusally far enough to make a clean margin, the occlusal wall is 
thereby rendered too weak to withstand mastication. All opera- 
tions performed upon these surfaces without extension must there- 
fore be considered in the light of temporary work. 



108 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

Sometimes such fillings do good service through the care with 
which they are inserted, coupled with the probable fact that just 
at this time the patient acquires a partial or complete immunity 
from caries. Many indifferent operations have received credit for 
being perfect owing to this very fact of immunity, and, as has al- 
ready been intimated, the whole question of periodical immunity 
and susceptibility of our patients in regard to the attack or progress 
of dental caries should receive more careful consideration than it 
does. But what concerns us now in treating the present subject is 
that clinical experience proves most of these small fillings to be 
temporary, and resort should be had to their occasional insertion 
with this fact clearly in mind. 

The plan of anchorage for such fillings is very simple. There 
is little stress to dislodge the filling, and all that seems necessary 
in the formation of the cavity is to make parallel walls surrounding 
it at right angles with the axial wall, and to bevel the enamel-mar- 
gins. 

Proximo-Occlusal Cavities in Bicuspids and Molars. 

Wherever decay has so invaded the proximal surface as to in- 
volve the occlusal surface, or wherever it is deemed necessary to 
open the cavity to the occlusal surface in those cases presenting 
with this wall still remaining, a new class of conditions confronts 
the operator. In view of the fact, as already intimated, that most 
proximal cavities in these teeth must be made to include the oc- 
clusal surface, it becomes necessary to study somewhat carefully 
the conditions governing the treatment of such cases. 

The principal objects to be attained in the insertion of this 
kind of a filling are, first, to check the existing decay; second, to 
prevent, so far as possible, a recurrence of decay in the future; 
third, to securely anchor the filling against displacement from the 
stress of mastication; and, fourth, to so restore the original form of 
the tooth that it will be maintained in its proper relation with the 
■other teeth and with the gum-tissue filling the interproximal space. 

The first of these requirements may be met by simply removing 
the decay and inserting a filling with perfect margins; and this 
would seem to be the limit of attainment with many operators. 



CLASSIFICATION AND PREPARATION OF CAVITIES. 109 

A failure to recognize other necessities in the case is accountable 
for much of the disappointment following these operations, 
through the temporary nature of such a line of work. 

The same general rules of extension for prevention apply to 
these cavities that were given for proximal cavities in the an- 
terior teeth, except that in bicuspids and molars esthetic con- 
siderations do not so materially affect the case, and the rules may 
therefore be less frequently waived on this account. The usual 
points of recurrence of decay around these fillings are at the 
gingivo-buccal and gingivo-lingual angles of the cavity, though in 
cavities left very narrow bucco-lingually the entire buccal and 
lingual margins may become involved. 

Another form of failure, where cavities are narrow in the region 
of the marginal ridge, relates to a fracture of the enamel at the 
proximo-occlusal angles. Enamel left in this form is easily broken 
down by the stress of mastication, causing a break between the 
filling and the margin. Fig. 51 illustrates a bicuspid with a nar- 
row filling a, points of recurrence of decay h h, and of fractured 
enamel c c. The line d indicates extension to avoid these forms of 
failure. 

The plan of anchorage for these fillings calls for careful con- 
sideration along the lines of the most approved mechanical princi- 
ples, and with a due regard for the location of the filKng and the 
probable stress to which it will be subjected in the process of mas- 
tication. The force of mastication varies greatly in different 
individuals, and the intelligent operator will take cognizance of this 
and govern his operations thereby. 

In estimating the probable durability of a filling and the extent 
of anchorage required to maintain it in place, a careful study 
should be made of the landmarks of mastication in the mouth un- 
der treatment. The expression "landmarks of mastication" is 
coined for the purpose of directing attention to this form of study. 
Mastication leaves its marks plainly and indelibly upon the teeth 
and upon fillings placed in them, and these markings offer a good 
index for the observant operator to estimate the probable average 
force exerted in ordinary mastication in a given mouth. The use 



110 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

of the gnathodynamoiiieter for the purpose of recording the stress 
of mastication, while very valuable for scientific study and for 
throwing much light on the possible force of mastication, is not 
considered to be the most reliable index to the force actually em- 
ployed in the comminution of food. The greatest possible force 
that can be exerted in closing the jaws is often far removed from 
the actual force used in mastication in the same mouth, and is 
not invariably relative to it. Tor this reason, if we accept it as 
our sole guide for the extent of anchorage required for our fill- 
ings, we shall in some instances subject our patients to unneces- 
sarily broad and painful cutting to accomplish an object which 
might have been attained by less heroic means. On the other 
hand, we may sometimes fall short of adequate anchorage in 
those cases where the gnathodynamometer gives a low record, but 
where the actual wear and tear on fillings in mastication is some- 
what severe. 

It is true we should aim in all cases to anchor our fillings in 
such security that the greatest possible stress of which the jaws are 
capable will not dislodge them, but the conditions under which we 
are compelled to operate will not invariably permit it. The 
requisite bulk of tooth-tissue is not always left for us by the carious 
process, and the sensibilities of our patient must also be considered. 
The same statement is true here which was used in connection with 
cutting cavities in anterior teeth, that we must not jeopardize the 
nervous system of our patient to follow out some heroic theory. 
The fact of ignoring the patient in these matters by a blind pursuit 
of an ideal in the mind of the operator is accountable for much of 
the aversion experienced against the dental chair, and we must 
have a care not to discourage people against permitting dental 
service to be done for them by too great a degree of severity during 
the operation. This does not imply that we must be slip-shod in 
our methods, or that we must at all times avoid giving pain. It 
is occasionally necessary to give pain, but the operator should care- 
fully study his patient and limit the discomfort to a reasonable de- 
gree of tolerance. (This matter will be considered more in detail 
in a subsequent chapter on the treatment of sensitive dentine.) 



CLASSIFICATION AND PREPARATION OF CAVITIES. 



Ill 



The landmarks of mastication relate to worn surfaces of enamel 
at points of occlusal contact which are evidently formed by me- 
chanical wear instead of by erosion, to deep indentations in fillings 
made by repeated and vigorous thrusts of the opposing cusp, and 
occasionally to fractured and jagged enamel showing evidence 
of rough usage. If the operator will give a careful study to the 
condition of his patients' teeth and watch for these markings he 
will soon be able to tell quite accurately the probable degree 
of service which a given set of teeth are called upon to do at table, 
and it will often guide him in his methods of anchoring fillings. 

The different plans of anchorage for these proximo-occlusal 
fillings in bicuspids and molars deserve careful consideration. The 



Fig. 51. 



Fig. £2. 






method almost universally employed in the past has been to cut 
a groove along the buccal and lingual walls of the cavity, and in 
some instances to groove the gingival wall. The limitations of this 
method relate to the insecurity of such anchorage against heavy 
stress, and to the danger of weakening the walls, particularly in 
those cases where the buccal and lingual outlines of the cavity are 
sufficiently extended for safety against recurrence of decay. 
Unless the grooves are very broad and deep — a condition disas- 
trous to cavity-walls — any tipping stress on such a filling will tend 
to lift it slightly away from the axial wall, leaving a leak along the 
filling at that point. Then, again, the occlusal aspect of this form 
of filling is ordinarily unsatisfactory. In bicuspids especially the 
filling encounters a fissure running mesio-distally between the 
cusps, and leaving at the junction of the filling and fissure a 
shoulder on the filling impossible of perfect finish, and an element 



112 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

of weakness in the probable recurrence of decay along the fissure. 
As has already been stated, a fissure is invariably a defect in the 
tooth whereby two islands of calcification have failed to coalesce 
in its development, leaving a break in the continuity of the enamel 
at that point and a crevice for the ingress of deleterious matter. 
It should therefore be the constant rule that whenever a cavity on 
the occlusal surface of a tooth encounters a fissure, the fissure 
should be drilled out to its extreme end and included in the cavity. 

What would appear to be a much preferable method of anchor- 
age to that just considered, and one offering greater security to the 
filling, is to create a step on the occlusal surface of the tooth at 
right angles with the proximal portion of the cavity, and extend- 
ing sufiaciently into the occlusal surface to effectively lock the 
filling into place. This also results in the obliteration of the fis- 
sure and the formation of a filling easy of finish. Fig. 52 shows 
the occlusal surface of a bicuspid with the original cavity a, — the 
form left by many operators, — 6 the fissure, and c the line of 
extension. 

With this form of anchorage the filling cannot be displaced 
short of a fracture of the filling or a stretching of the material at 
the point where the proximal portion joins the occlusal, through 
repeated impacts of the opposing cusp in mastication. To prevent 
this the cavity should be made deep enough at this point to allow 
of sufficient bulk of filling-material for strength, and the material 
should be thoroughly packed and well condensed to give it the 
greatest degree of resisting power. 

Another point in connection with the dislodgment of these fill- 
ings relates to the form of the occlusal surface of the filling and 
also the form of the cusps on the opposing teeth. While the 
general rule holds good that in the formation of fillings they should 
be made as nearly as possible to reproduce the original form of the 
tooth, yet in these proximo-occlusal fillings a slight modification 
of the original form is often advisable. In the natural form we 
find the marginal ridge of enamel standing more prominent than 
the enamel between the cusps, thereby receiving greater impact in 
the process of mastication. If in the insertion of the filling we 



CLASSIFICATION AND PREPARATION OF CAVITIES. 113 

reproduce the marginal ridge, we subject the filling to too great 
leverage at a point where it has a tendency to tip away from its 
anchorages. This may be avoided by making the filling as high 
as possible midway between the cusps, and sloping it toward the 
contact point in such a way as to avoid making a marginal ridge 
and to present a gradual incline from the highest point between 
the cusps to the point of contact on the proximal surface. In 
doing this the occlusal surface of the filling is so presented to the 
cusp of the opposing tooth that the tendency on closure of the jaws 
is to force the filling laterally into the cavity against the axial wall 
instead of lifting it away, as would result if the marginal ridge 
were reproduced. Fig. 53 a shows the section of a bicuspid mesio- 
distally with filling in place and the marginal ridge reproduced. 
The cusp of the opposing tooth would tend to tip the filling in the 
direction indicated by the arrow. Fig. 53 & shows sloping filling 
with the direction of force diverted against the interior of the 
cavity. 

This plan does not materially impair the efficiency of the tooth 
for mastication, but even if it did lessen the masticating area some- 
what it would still be justifiable on the ground that a tooth with 
its masticating area reduced one-half, but containing a filling safely 
anchored and enamel so sloped as to avoid fracture, is more valu- 
able than one presenting a full masticating area subject to the 
danger of filling displacement and fractured enamel-walls. This 
does not imply that the filling should be made narrower mesio- 
distally at the contact point than the tooth originally was. For 
reasons which will appear later the full width of the tooth must be 
maintained wherever possible. This may result in some instances 
in the point of contact with the proximating tooth being carried 
slightly rootwise of the original contact, but if care is exercised 
this may safely be done without impairing the efficiency of the 
contact or interfering with the gum-tissue in the interproximal 
space. 

The treatment of the cusps of opposing teeth coming against 
these fillings is a matter of much importance, particularly with 
bicuspids. When the sharp buccal cusp of a lower bicuspid 



114 PBINCIPLES AND PEACTICE OF FILLING TEETH. 

impinges so far into a cavity on the opposing upper bicuspid as to 
necessitate making the filling too thin for strength, or where it 
passes so far between the cusps of the upper tooth as to form a 
wedge capable of splitting the tooth, the tip of the cusp on the 
lower bicuspid should be ground down so as to shorten it and 
present a broad surface to the upper tooth instead of a wedge 
shape. This will result in the formation of a thicker and stronger 
filling in the decayed tooth, and such a change in the direction of 
force exerted by the lower tooth as to minimize the danger of 
splitting its opponent. With a wedge-shaped cusp there is much 
lateral force exerted buccally and lingually against the cusps of the 
upper tooth, but with a broad, flattened cusp the direction of force 
is more nearly parallel with the long axis of the tooth and the 
tendency to split is lessened. This grinding, if done judiciously, 
will not interfere with the usefulness nor impair the integrity of 
the lower bicusjjid. The enamel is very thick at that point, 
and there is little liability to decay, so that this method should 
be employed quite frequently for the greater permanence of our 
fillings and the greater safety of the teeth, especially in those 
cases where the cusps of the lower teeth are very prominent and 
sharp. 

One of the most important considerations in the management 
of these proximo-occlusal cavities relates to the form of the filling 
on the proximal surface. It should be so built out to a contour 
that the tooth will be maintained in its proper position in the arch, 
and that the gum-tissue in the interproximal space shall be pro- 
tected and preserved in a healthy condition. When the teeth stand 
in their normal relation in the jaws they are supported on their 
proximal surfaces by contact with the tooth next in line^ and the 
interproximal space between these points of contact and the border 
of the alveolar process is filled with gum-tissue. This gum-tissue 
has an arched form bucco-lingually, with the crest of the arch near 
the contact point; and this form facilitates the cleansing of the 
space by a deflection of the food buccally and lingually in mastica- 
tion. So long as the contact points are small and the space of 
normal form and fllled with gum-tissue, foreign material will not 



CLASSIFICATION AND PREPARATION OF CAVITIES. 115 

find a lodgment in the space. In the comminution of fibrous 
food, such as meat, the fibers may occasionally be forced between 
the contact points, but they are not retained there on account of 
the narrowness of contact. The next passage of food on closure of 
the jaws in being squeezed out buccally and lingually along the 
incline of gum will catch them and carry them with it, leaving the 
space clean. 

When decay takes place on the proximal surface and the con- 
tact point breaks down, the teeth, lacking proximal support, have 
a tendency to drop together, forcing the gum from between them 
and narrowing the space. In cases of extensive caries the teeth 
may so change their position as to practically obliterate the space 

Fig. 54. Fig. 55. Fig. 56. Fig. 57. 






and crush out all of the gum-tissue, leaving the buccal and lingual 
festoons of the gum more prominent than that portion midway 
between the teeth. This results in an inverted arch to the gum, 
and produces a pocket between the teeth which is especially f avor- 
aljle to the reception and retention of food debris. Fig. 54 illus- 
trates the proximal surface of a sound lower molar with the gum 
covering it in a normal arched form; Fig. 55, a similar case, 
with proximal decay and an inverted arch to the gum, forming 
a pocket. When caries occurs in this way the necessary pro- 
cedure to restore the gum to health is to Avedge the teeth apart to 
their original position, and then to so contour the filling that they 
will be maintained there. 

If the filling is inserted without this precaution the result is a 
broad, flat proximal surface to the filling, which will catch fibers 
of food and retain them to decompose. This wedging of food 
between teeth is an element of great discomfort to the patient, 
and a prolific source of failure in these proximal fillings. It not 
only results in recurrence of decay, but sadly impairs the health of 



116 PKINCIPLES AND PRACTICE OF FILLING TEETH. 

the gum and pericemental membrane. ]^o operation should be 
considered satisfactory which does not include in its performance a 
due regard for the form of the interproximal space and the health 
of the gum-tissue within it. 

The attempt to prevent food from wedging between teeth by 
making broad contacts built tightly against the proximating tooth 
usually fails in its object through the fact that contact cannot 
in this way be made so perfect that at times the individual move- 
ment of the teeth one against the other will not result in the 
passage of fibrous food between them. When it once makes its 
way between the filling and the proximating tooth, it is firmly 
held there by the broad contact. The only safe form to give these 
fillings is to make a narrow rounded contact, sufiiciently dense to 

Pig. i8. Fig. 59. 





maintain the teeth in position and to preserve its form against the 
wear occasioned by the individual movement of the teeth. This 
wear is sometimes quite severe, as is shown by the facets worn in 
the enamel on the proximal surfaces of many sound teeth. This 
recalls the fact that these worn facets are often a prolific source of 
discomfort to the patient, even where there is no decay; and in 
those cases where a filling is being built in a cavity proximating 
a tooth with an extensive facet, the margins of the facet should be 
slightly rounded off to produce an oval form to the surface. The 
attention of the operator should not be limited to the single tooth 
being filled, but he should study carefully the adjacent parts, to the 
end that the teeth and gums in the entire region be placed in the 
best possible condition. 

Fig. 56 shows the buccal surfaces of two lower bicuspids and the 
first molar. There is no decay between the bicuspids, and the 
contact is normal and gum healthy. Between the second bicuspid 
and first molar decay has taken place on both proximal surfaces, 



CLASSIFICATION AND PREPARATION OF CAVITIES. 117 

allowing the teeth to fall together and obliterate the space. The 
congested buccal festoon of gum is shown opposite the original 
position of the space. Fig. 57 illustrates the same two teeth when 
wedged apart and contour fillings made to reproduce the inter- 
proximal space. The gum-tissue is seen reoccupying the space 
in a normal condition. Fig. 58 represents the occlusal aspect of 
the case, with outline of fillings and point of contact. Fig. 59 
shows a section mesio-distally at the contact point. 

In view of the importance of making contact points of the 
proper form and size on all proximal fillings, it would seem neces- 
sary to study somewhat carefully the precise form and the exact 
area of contacts found in normally shaped sound teeth. To make 
an ocular examination of the teeth in the mouth is somewhat mis- 
leading. With the teeth standing in line in the arch and the 
gums filling the interproximal spaces, the appearance would tend 
to convey the impression that a much larger area of enamel was 
in contact than is actually the case. The presence of foreign ma- 
terial or even of moisture clinging to the proximal surfaces ob- 
scures the vision so that a true estimate can never be made by this 
kind of examination. JSTeither will an operator be likely to gain a 
clear conception of the area of contact by an examination of the 
teeth singly out of the mouth unless in cases of worn facets, which 
should not be considered as typical or normal contacts. The 
variation in the breadth of the proximal surfaces of the different 
teeth would seem to imply that there must be a like variation 
in the area of contact, but this is by no means the case. 

The fact is that the area of enamel in actual contact even 
between the broadest molars is normally almost infinitesimal, and 
the surest means of determining this beyond any possibility of 
doubt is to take two such teeth that have been extracted, and, 
placing them together in the same relation to each other which 
they sustained in the mouth, hold them up to the light with the 
buccal surfaces presented to the operator. It will be seen at 
what a minute point the light is obscured by contact, — a point so 
very small as scarcely to admit of measurement. Now turn the 
teeth so that the occlusal surfaces are presented to the operator 



118 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

and a similar result is apparent, or if possible intensified. This 
is an object lesson in the area of contact between teeth at once so 
apparent and so vivid that the experiment should not be ignored 
by any dentist who is called upon to fill cavities in these surfaces. 

This must not imply that all proximal surfaces have the same 
form, or that the contact points are located in the same place on all 
teeth, A close study of the anatomical features of the proximal 
surfaces of the different teeth will reveal a great variation in form,, 
and this variation should be respected in the building of fillings. 
For instance, a lower second bicuspid usually presents a proximal 
surface somewhat rounded bucco-lingually at the contact point, 
and sloping away from this point buccally and lingually with a 
relatively equal degree of curvature. This brings the contact 
point nearly midway between the buccal and lingual surfaces, and 
calls for a generally rounded form to the filling. On the contrary, 
the upper first molar presents on its mesial aspect a greatly flat- 
tened surface with the contact point located much nearer the 
buccal than the lingual surface, and sloping away abruptly toward 
the buccal and gradually toward the lingual. Speaking in a gen- 
eral way, it will be found that in making the contact point on 
fillings the distinction should be made between the upper bicuspids 
and molars and the lower ones, that on the former it should be 
located much nearer the buccal than the lingual surface, while 
on the latter it should be more nearly midway between the two. 
The location of the contact point occluso-gingivally is quite uni- 
form in both jaws, the common rule being to find it near the oc- 
clusal surface sloping abruptly with a sharp curve toward this 
surface and falling away gradually toward the gingival. 

There is often a marked difference between the prominence 
of the contact point on the mesial and on the distal surfaces which 
applies to both the upper and lower teeth, the distal surfaces 
usually presenting a bolder and more rounded prominence than the 
mesial, and therefore curving sharply to the gingival. This re- 
sults in such a form to the interproximal spaces that they incline 
with their apices directed somewhat backward, and their mesial 
boundary a trifle larger than their distal. 



CLASSIFICATION AND PREPAEATION OF CAVITIES. 119 

To gain the most intelligent idea of the actual form of the in- 
terproximal spaces and the variations in the proximal surfaces 
of the teeth, a close study should be made of a well-formed jaw 
from a skeleton with the teeth in their normal position in the arch. 
An examination of such a jaw from the buccal, the lingual, and 
the occlusal aspects will place the operator in a more enlightened 
relation to the subject than can be attained in any other way. 

In judging the area of contact between teeth in the mouth or 
between fillings, the most convenient test is the ligature. If a 
ligature be passed between the proximal surfaces of teeth having 
normal contact points it will bind quite tightly near the occlusal 
surfaces as if meeting a sudden obstruction, but this obstruction 
is narrow and the ligature readily springs past it under pressure, 
and moves back and forth with the greatest freedom in the inter- 
proximal space. In lifting the ligature out of the space it should 
pass nearly to the occlusal surface before being engaged by the 
contact points, and should then come out from between the teeth 
with a sudden snap. If the ligature drags in passing the con- 
tact points, or if it is frayed against the surfaces, the contact is not 
normal whether it be on a filling or on a tooth. 

Separating the Teeth. 

In those cases where the decay has not progressed very far 
and where there has been little breaking down of the contact 
point and consequently no dropping together of the teeth, suf- 
ficient space may often be obtained by the separator, the proper 
use of which has already been indicated. But where any con- 
siderable movement of the teeth is necessary it is more safely 
and comfortably accomplished by gradual wedging. The same 
system may be employed as was advocated for anterior teeth, with 
the exception that a more extended use may be made of gutta- 
percha. This substance, if properly employed, is really the ideal 
material for separating bicuspids and molars, and its more gen- 
eral use would do much to remove the prejudice existing against 
having teeth wedged. 

It may be used in the following manner: The occlusal wall 



120 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

should be broken down in those cases where it is still standing, 
and the cavity cleared of debris and softened dentine with a few 
sweeps of a broad spoon excavator. It should then be flooded 
with an essential oil and the excess wiped out, leaving the cavity- 
walls soaked in the oil. Gutta-percha should then be packed into 
the cavity and snugly against the proximating tooth, so that 
pressure may be exerted between this tooth and the axial wall of 
the cavity. The gutta-percha should be built up sufficiently for 
the cusp of the opposing tooth to impinge upon it in closing the 
jaws, and the repeated impact thus resulting will tend to spread the 
gutta-percha and force the teeth apart. By this method teeth 
may be separated with very little soreness, it being the rarest ex- 
ception for a patient ever to complain of this sort of wedge. The 
process is somewhat slow, but it may be hastened in emergency 
cases by first applying the separator and lifting the teeth as far 
apart as practicable before packing the gutta-percha. Ordinarily 
without the use of the separator the gutta-percha may be left in for 
a week, and if at the end of that time there is not sufficient space, 
fresh gutta-percha may be added and the case dismissed for another 
week. 

To economize time in the management of these cases, it is well 
for the operator, on examining a mouth where several fillings are 
needed, to select these proximal cases at the first sitting and 
pack gutta-percha in each of them. He may then proceed with 
the other necessary work in the mouth, and by the tilne that is com- 
pleted some of the teeth thus wedged will be found ready to operate 
upon. The more stubborn cases may be left till the last, and, if 
necessary, the gutta-percha may be renewed in these as the other 
operations are under progress. 

Where the cavity slopes so rapidly from the axial wall to the 
gingival margin as to result in a sliding of the gutta-percha into 
the interproximal space instead of exerting lateral pressure, the 
gingival wall should be somewhat flattened previous to inserting 
the wedge. The gutta-percha will then rest on a broad base and 
will spread under pressure, exerting force in the required direc- 
tion. 



CLASSIFICATION AND PREPARATION OF CAVITIES. 121 

When gutta-percha is used in this way, or when it is employed 
for sealing medicaments in proximal cavities or for any tem- 
porary purpose, it should be so built out buccally and lingually 
as to impinge on the buccal and lingual festoons of gum to force 
them back on a level vnth. the gum midway between the teeth. 
There are two reasons for doing this. It keeps the festoons out 
of the way during the operation, thus preventing their laceration 
by files or finishing strips and affording better access to the work, 
and it also leaves the gum in the best possible condition for re- 
occupying the interproximal space after the operation. If the 
festoons are left higher than the gum between the teeth, it results 
in an inverted arch or pocket into which food may pack, thus re- 
tarding the healthy growth of the gum. If the festoons are 
pressed back so that they are not lacerated and a favorable form is 
left to the gum after operating, it will be found that the gum will 
quickly creep back into the space and occupy it in a healthy condi- 
tion. 

Details of Cavity Formation. 

In those cases where the occlusal wall is still standing and it 
becomes necessary for the operator to break it down, it is a matter 
of some importance to know how to do it to the best advantage. 
The arch of enamel overhanging the cavity at this point is often 
strongly resistant, and if the attempt is made to crush it in with a 
chisel, as is frequently done by operators, the result is ordinarily 
a somewhat severe shock to the patient. This shock, coming in 
the early stages of the operation, has a tendency to unnerve the 
patient and create an apprehension which often lasts through the 
entire sitting. As has already been intimated, all unnecessary vio- 
lence must be avoided, particularly when the patient first takes the 
chair. 

To open these cavities comfortably, a slot should be drilled 
through the arch as illustrated in Fig. 60, which practically re- 
moves the keystone of the arch and destroys its main support. 
If a small sharp drill be used, with the engine revolving rapidly, 
this slot may be made without appreciable discomfort, and the en- 
amel may then be broken down with a chisel, as shown in Fig. 61. 



122 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

The chisel should be held at the angle indicated and pressed 
firmly against the enamel to prevent gliding. If the proper angle 
be maintained, it will require only the slightest tap of the mallet to 
break the enamel away. Chisels for cleaving enamel should be 
made keenly sharp, so that they "bite" into the surface imme- 
diately at the point where they are held, instead of sliding along 
the surface with a grating, rasping sensation so distressing to 
most patients. 

After the cavity has been thoroughly opened, the walls may be 
formed as follows: 

The gingival wall. The margin of this wall should be extended 
far enough rootwise to carry it well under the gum in accord- 
ance with the outline in Fig. 51. The degree of extension will 

Fig. 60. Fig. 61. Fig. 62. Fig. 63. Fig. 64. Fig. 65. 





differ in different cases. In those teeth where there has been little 
decay and where the gum fills the interproximal spaces normally 
to the contact points, it will not require much extension to bring 
the margin safely under the gum; but in mouths where the gums 
have receded in the spaces and where the tendency to proximal 
decay is great, it will call for more extensive cutting to insure the 
most permanent operation. 

In other cases where there has been great recession of the gums, 
but where the gum tissue is firm and otherwise normal, and where 
the cavity has occurred near the contact point, with a considerable 
area of sound enamel between the gingival margin of the cavity 
and the gum, it would be too radical to cut through this sound 
enamel to bring the margin under the gum, nor do such cases call 
for it. They ordinarily belong to adult life where the suscepti- 
bility to recurrence of decay is lessened. 

The form of the wall bucco-lingually should be flat, and it 



CLASSIFICATIO:!^ AKD PREPARATION OF CAVITIES. 123 

should be made wide enough in this direction to furnish a broad 
base for the filling to rest upon and to bring the gingivo-buccal and 
gingivo-lingual angles to a point of safety against recurrence of 
decay. The wall should also be flat mesio-distally, and it should 
join the axial wall at right angles. In some instances, where great 
security of the filling is required, or where it may seem difficult to 
start the filling, the wall may be made to dip slightly rootwise as it 
approaches the axial wall, but a groove should not be drilled along 
the gingival wall, as is often advocated. To groove this wall re- 
sults in the formation of a ridge of tissue along the margin of the 
cavity, against which it is difficult to adapt gold without injuring 
the enamel. 

As the gingival wall joins the buccal or lingual wall it should 
form a distinct angle in the axial region, but should execute a 
short curve at the enamel-margin. The angle thus formed in the 
gingivo-linguo-axial corner of the cavity forms an excellent means 
for securing the first pieces of gold in position, and the general 
form of the gingival wall when shaped as just outlined affords a 
base upon which the filling may be built without danger of the 
gold rocking under the plugger-point. A rounded gingival wall, 
or in other words a curved base, is responsible for much of the 
difficulty experienced by some operators in starting these fillings. 

The width of the wall mesio-distally must be governed by the 
extent of tooth-tissue available. The cavity should have as wide 
a base as possible without endangering the pulp. In this con- 
nection the location of the pulp-chaml)er in tlie various teeth 
should be carefully studied by the operator, so that he may judge 
intelligently how far he can extend his cavities with safety. Fig. 
G2 illustrates a section of a bicuspid mesio-distally with the form 
of the gingival wall. 

The buccal and lingual walls. As already intimated, the form 
usually given these walls by operators is to groove them with the 
idea of anchoring the filling, — the limitations of which method 
have already been pointed out. There are some cases, it is true, 
where these walls must be made to sustain the filling; such, for 
instance, as lower first bicuspids with an exceedingly long buccal 



124 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

<}"usp and a diminutive lingual cusp joined by a perfect fusion of 
enamel. In tliese cases we iiave no opportunity for creating a step 
on the occlusal surface, and really little necessity for doing so, 
owing to the conical shape of the teeth and the consequent limited 
tipping stress on the filling. The occlusal surface of a proximal 
filling in one of these teeth presents a sloping surface to the 
cusp of the upper tooth, and there is practically no leverage to dis- 
lodge it. A slight buccal and lingual retention in the form of 
shallow grooves in connection with a broad, flat seat or gingival 
wall is all that is required to retain the filling. 

But for ordinary cases grooving along these walls should be 
avoided, though a possible retentive shape should not be ignored 
in their formation. This may be secured by making an angle 
between these walls and the axial wall in such a way that the cavity 
is slightly wider bucco-lingually at the axial wall than it is at the 
dentinal enamel-margin. (Fig. 63.) This may be done without 
materially weakening the walls, and the mortise or dovetail form 
thus provided is an element of security to the filling. This mor- 
tised effect should be carried from the gingival wall throughout 
the length of the buccal and lingual walls till they approach the 
enamel on the occlusal surface, where they should merge into the 
form shown in Fig. 52, c. This kind of wall presents a surface 
against which gold may readily be adapted, and the filling-material 
once locked between these two perpendicular walls is securely held 
in place. The building of fillings in cavities thus formed is a very 
simple matter. 

Tlie step. This should be cut at right angles with the prox- 
imal portion of the cavity, and should present a flat base for the 
filling-material to rest upon. Its width bucco-lingually and its 
depth pulpally should be governed by the form of the tooth. If it 
is a short, thick tooth, the step should be made correspondingly 
wide, with a diminished depth, while if the tooth be long and thin 
the step may be narrowed and deepened.^ The object in any case 
is to secure a sufficient bulk of filling-material in the step to afford 
strength, — ^which is particularly true at the point where the step 
joins the proximal portion of the cavity. The step should be 



CLASSIFICATION AND PEEPAEATION OF CAVITIES. 125 

made as wide and deep here as is practicable without ■undermining 
the cusps or weakening the tooth between the cusps so as to render 
it liable to split. Particular study, especially in bicuspids, should 
be given to this question of splitting in its relation to the depth of 
the step pulpally. A safe rule to follow is to drill as deeply be- 
tween the cusps as the fissure extends pulpally, and make the base 
of the step at this point. This cannot result in any greater ten- 
dency to fracture than existed before, because of the fact that 
wherever there is a fissure there is no binding strength repre- 
sented throughout its extent. 

The buccal and lingual walls of the step should be made per- 
pendicular, with an angle between them and the pulpal wall. The 
end of the step most remote from the proximal portion of the 
cavity should also have a perpendicular form, and the step at this 
point may often be widened bucco-lingually in those teeth having 
a notable depression on the occlusal surface at the termination of 
the fissure. This results in a dovetail form which aids in the reten- 
tion of the filling. 

The axial wall. The shape of this wall will be governed mate- 
rially by the depth of the decay. Where there is little penetration 
of the carious process it should be made perpendicular and at 
right angles with the gingival wall. In cases of deep decay with 
a concave axial wall it may be well to create a new axial wall with 
cement, which will afford protection to the pulp and give a better 
form to the filling. The cement should not be built out so far 
as to result in leaving the metal filling too thin for strength. 
Veneer fillings of this character cannot be depended on for ex- 
tended service. The axial wall should never be left sloping from 
the step to a narrow gingival wall, on account of the tendency of 
the filling to shift under stress when built against an inclined 
surface such as this would present. 

The enamel-margins. The buccal and lingual margins should 
be beveled to a greater extent than in any other part of the outline 
of the cavity. The gingival margin need be beveled but very little 
on account of the lack of lateral violence against such a surface, 
and also because of the difficulty of producing a perfect bevel in 



126 PEINCIPLES AND PKACTICE OF FILLING TEETH. 

this region and building the gold over it. On the occlusal surface 
the slope of the enamel down to the cavity-margin and the proper 
shaping of the walls result in a margin which requires very little 
beveling by the operator. Care must of course be exercised that 
in forming the margins no overhanging enamel be left. If the 
slightest ledge of unsupported enamel is allowed to remain, it will 
quickly be fractured by the stress of mastication. 

Technique. — In opening the cavity all friable or overhanging 
enamel should be broken down by chisels, and in this connection 
some study should be made of the proper angle at which a chisel 
must be held in order to cleave enamel to the best advantage. 
Enamel will bear appreciable pressure without fracture if the force 
is exerted upon it in certain directions, but a slight deviation of 
the force may be made to result in a ready parting of the enamel- 
prisms. Advantage should be taken of this characteristic of 
enamel so that overhanging walls may be broken down with the 
least possible force. Little can be definitely taught as to the 
precise angle at which the chisel should be held for the best results 
in varying cases, but the observant operator will readily learn to 
detect the vulnerable points in overhanging enamel and know best 
how to attack it. 

The character of the force exerted on the chisel also becomes im- 
portant. Wherever an angle of enamel is ito be broken down or 
where there is any appreciable bulk of tissue to be cleaved away, 
it is best and most comfortably accomplished by a sharp, decisive 
blow of the mallet on the chisel. But Avhere it is merely a question 
of cavity extension or a trimming of ragged or frail walls, hand 
pressure on the chisel is preferable. When used in this way care 
should be exercised not to allow the chisel to slip into the cavity 
and impinge on sensitive tissue. The hand should be guarded and 
kept under perfect control by bracing the ends of the fingers — the 
ones not used in holding the chisel — firmly against the teeth. 
This work may in certain positions be best accomplished by grasp- 
ing the chisel in the palm of the hand and allowing the end of the 
thumb to rest against the teeth as a brace. 

The next step is to give form to the cavity-walls. An inverted 



CLASSIFICATION AND PREPARATION OF CAVITIES. 127 

cone bur of sufficient size to cover the gingival wall mesio-distally 
should be jDlaced with its end on this wall, as illustrated in Fig. 64, 
and carried buccally and lingually along the wall till the proper 
extension is reached. This will give a flat form to the gingival 
wall and create an angle between it and the axial wall. Care 
should be exercised that the blades of the bur do not penetrate too 
close to the pulp. The buccal and lingual walls may often be 
extended with the same bur by carrying it up and down along these 
walls, — cutting with the side of the bur. In lower teeth, or in 
distal cavities diflicult of access in upper teeth, an inverted cone bur 
in the right-angle hand-piece will be most effective. After the 
walls have been extended with the large bur it will be found that 
the angles between the buccal and axial or lingual and axial walls, 
and particularly in the gingivo-bucco-axial and gingivo-linguo- 
axial corners, are not sufficiently well defined. A smaller in- 
verted cone bur used in the same way may be carried into these 
angles to deepen them, and if a still sharper angle be required it 
can be made with hatchet or hoe excavators. 

As the small inverted cone bur is being used along the gingival 
wall it should be carried laterally somewhat into the buccal and 
lingual walls at this point and then withdrawn a short distance 
crownwise along the gingival third of these walls. This wdll result 
in an angle or pocket into which the first pieces of gold may readily 
be secured. Such a form as this is especially serviceable for begin- 
ners, who may otherwise find difficulty in starting these fillings. 
If there be much softened dentine along the axial wall it may be 
removed with spoon excavators. 

In forming the step, the fissure on the occlusal surface may be 
opened up with a small drill, a suitable form for this purpose being 
readily made from a worn-out inverted cone bur by grinding it on 
two sides to a sharp edge, as illustrated in Fig. 65. This form of 
drill, small in size and ground sharp, may be made to walk directly 
through between the two plates of enamel bordering a fissure by 
revolving the engine rapidly and swaying the hand-piece back and 
forth, so that the sharp corners of the drill effectively bite into the 
enamel. When a narrow trench is thus made it may be widened 



128 PKINCIPLES AND PKACTICE OF FILLING- TEETH. 

with a chisel, after which the floor of the step may be formed with 
an inverted cone bur stood with its end on the step. This results 
in the desired flat base to the step, while the sides of the bur give 
form to the walls. 

The gingival enamel-margin may be given the slight degree of 
bevel necessary with suitably formed chisels or long-shanked ex- 
cavators. Sometimes in cases of good access a round bur may be 
passed along this margin to advantage. For beveling the buccal 
and lingual enamel a thin, sharp chisel may be used to plane down 
the peripheral margin, but what is far preferable in those cases 
where it can be used is a sand-paper disk in the engine. This, if 
held at a definite angle, will give the required bevel, and will leave 
a margin clearly cut, symmetrical, and smooth. Care must of 
course be exercised not to round the margin with the disk by sway- 
ing the hand-piece as the disk is revolving. 

General Considerations. 

While the form of cavity here recommended is believed to be the 
best adapted for the majority of cases applying to the dentist, it is 
acknowledged that there are many instances where it cannot well 
be followed out in all of its details. The extent of the decay is 
sometimes so great as to determine the shape of the cavity-walls, 
and where there has been much undermining of the tissue the 
operator is left to make the most of the opportunities presented; 
but the principles involved in cavity formation should never be 
lost to view, and every cavity should be made to conform to them 
as accurately as the case will permit. 

A distinction is sometimes made in these cavities between those 
intended for gold and those for amalgam. So far as the general 
form of the cavity is concerned, there should be no distinction, 
except that for amalgam more extensive anchorage is usually 
required than for gold. Gold if properly condensed is so stable 
and uniform in its behavior that it may be depended on to remain 
placed in a cavity where amalgam with its freaks and fancies will 
too often prove insecure. With most of the amalgams in use it 
requires a much greater bulk of the material to stand a given stress 



CLASSIFICATION AND PEEPAEATION OF CAVITIES. 129 

than it does of gold, and the anchorages must therefore be broader 
and deeper, and the bevel of enamel along the margins not quite 
so great. With these exceptions the plan of cavity formation 
should be the same. 

One feature relative to the security of these fillings in bicuspids 
and molars should not be overlooked in estimating the extent of 
anchorage required. It is too often the case that operators insert 
these fillings without an adequate study of the kind of service they 
are destined to perform. Even if they stop to consider the force 
of mastication in its relation to the extent of anchorage, it is usually 
only \vith the idea of a given number of pounds pressure which 
may be exerted on the filling, and the probability of a certain area 
of anchorage withstanding such a pressure. They do not con- 
sider in its full significance the feature of aggregate service. It is 
the constant dripping of water which wears away the stone, and in 
anchoring these fillings we must provide against a series of masti- 
cating impacts so numerous in extent as to stagger one who has 
not studied the matter. Persons vary greatly in the number of 
occlusions they make during a meal, as they do in the degree of 
force used in masticating, but a somewhat close observation would 
lead to the belief that for the proper mastication of an average 
dinner the individual will make at least one thousand distinct 
occlusions, and in many instances it will greatly exceed this. Let 
us stop to consider what this means for our filling. Suppose one- 
half of these impacts fall on one side and that one-half of these 
come against the filling. This is really a low estimate, because 
many persons will manage a bolus of food on each side of the 
mouth at the same time, and this bolus will extend over several 
teeth. At a moderate computation each meal will result in nearly 
three hundred impacts of food against the filling, varying in force 
and cliaracter according to the habit of the individual and the 
nature of the food. AVhen it is remembered that this process ia 
kept up three times a day for three hundred and sixty-five days 
in the year, it will soon become manifest that our fillings must be 
anchored against some pretty severe usage, and, with such a reck- 
oning as this constantly V>efore him, the conscientious operator will 

9 



130 PBINCIPLES AND PRACTICE OF FILLING TEETH. 

proceed to his work witli the. greatest oare and thoroughness, to 
the end that it may be made as permanent as possible. 

A close study of the process of mastication in the operator's 
own mouth in its relation to this subject is strongly recommended. 
The nature and extent of the force used, together with the manner 
of its application in the comminution of different food materials, 
are fit subjects for careful observation; and an intelligent compre- 
hension of the forces at work in the performance of mastication 
will place the operator in a better position to render the most per- 
fect service. 

Buccal, Labial, or Lingual Cavities. 

All cavities occurring in either of the three surfaces — buccal, 
labial, or lingual — call for similar treatment so far as the prin- 
ciples of cavity formation are concerned, except the small rounded 
cavities having their origin in the pits on the buccal surfaces of 
lower molars and the lingual surfaces of the upper anterior teeth. 
These pitted cavities are quite distinct in character and environ- 
ment from the ordinary buccal and lingual decay occurring near 
the gum-margin, and their preparation is so self-evident as not to 
call for any extended or detailed description. The fact that they 
are usually the result of structural imperfections in the tooth at 
the point of decay, and that they occur in surfaces which are ordi- 
narily readily cleansed by friction, renders it necessary only to 
remove the carious and imperfect tissue, secure good margins, and 
give a mortised form to the cavity. JSTo extension for prevention 
is required in these cases. 

But where decay occurs near the gum-margin and extends in a 
crescent form, following the outline of the gum along the surface 
of the tooth, the problem of its control becomes more complicated. 
These are sometimes accounted the most difficult of all cavities to 
deal with, and yet if properly managed they will respond to treat- 
ment with most gratifying results. 

The cavity outline. The proper marginal outline of the cavity 
becomes a matter of vital importance in its relation to the probable 
permanence of the operation. The reason that many of these fill- 



CLASSIFICATION AND PREPARATION OF CAVITIES, 131 

ings fail so early after their insertion may be traced to the fact that 
in the preparation of the cavity the margins are not extended to 
include all of the affected enamel. If we study the manner of 
progress of this form of decay, it will enlighten us greatly as to the 
necessities of the case in treatment. Occasionally we may find 
these cavities well defined in outline with a notable penetration of 
decay at a given point, and when such is the case with a surround- 
ing surface of perfect enamel our method of procedure is clear. 
We need very little extension of the margins. 

But in the vast majority of cavities occurring in these surfaces 
it will be found that the area of decay is ill defined, and that the 
enamel is more or less disintegrated along the surface leading from 
the cavity and following the margin of the gum. This affected 
enamel must invariably be included in the cavity outline and 
replaced by filling-material if we are to be assured of permanent 
results. The fact that disintegration has commenced is conclusive 
evidence that the active agent of caries has found this particular 
point of the surface a suitable field upon which to work its destruc- 
tive processes, and the assumption is clear that unless the condi- 
tions are radically changed the process will continue. The surest 
method of changing the conditions is to remove the area of tissue 
upon which the micro-organisms of caries are known to act, and 
replace it with filling-material upon which they cannot act. This 
one fact that enamel is vulnerable to the attack of micro-organisms, 
while filling-material is not, should give us a clearer conception of 
the required line of treatment in all those positions which are sub- 
ject to the influence of the destructive agent. The broader we 
make our metal surface at the expense of the enamel-surface, the 
more certain we are to avoid a recurrence of decay, and yet this 
does not imply that Ave must ruthlessly or ill-advisedly carve away 
sound enamel for the purpose of making a broad metallic area. 
It simply implies that we shall not stop short of reaching perfectly 
sound enamel in the extension of these cavities, and that particu- 
larly in positions suitable for the lodgment of micro-organisms we 
shall be especially thorough. 

The surface of the enamel surrounding one of these cavities 



132 PRINCIPLES AND PKACTICE OF FILLING TEETH. • 

must be critically examined for defects. Sometimes a crescentic 
line of discoloration extends from the cavity in such a manner as 
to confuse the operator with regard to the true condition of the 
enamel under it. It may be simply a discoloration on the surface, 
with sound enamel below it, or the enamel may be softened to con- 
siderable depth and the discoloration tend to hide the defect. The 
only way to determine the true condition of the enamel is to thor- 
oughly polish away the discoloration with pumice carried on a 
brush in the engine. If the brush succeeds in removing all the 
discoloration, leaving a white and glistening surface to the enamel, 
we may know that the destructive agent of caries has not yet 
affected it; but if the enamel shows disintegration on its surface 
after the brush has been used, we must cut out this disintegrated 
tissue, even if it has not already penetrated the entire depth of the 
enamel. 

The proper extension of the cavity rootwise involves the carry- 
ing of this margin well under the gum. There are two reasons for 
this, — first, the one already given in connection with proximal 
cavities, that wherever the filling is carried under the free margin 
of the gum there will be no recurrence of decay at that point, and 
second, that the gum is more likely to remain healthy when over- 
lapping a smooth gold filling than when overlapping tooth-tissue, 
particularly if there has been any recession of the gum. This 
latter statement may appear illogical at first thought, but a some- 
what close clinical observation would seem to confirm it beyond 
any doubt, and a careful study of the conditions will suggest a 
tenable reason therefor. In all cases where there has been any 
extended decay it will be found that the margin of the gum has 
been interfered with in one of two ways. Either the decay has 
crept up under the gum, leaving the free margin lying in the 
cavity in ah unhealthy condition, or else the gum has progressively 
receded and is lying against the cementum instead of enamel. In 
the latter case the gingival outline of the cavity is usually ill 
defined, with little penetration of the carious process. Under 
either of these conditions the gum will be found abnormal. If in 
the preparation of the cavity we press back the gum gently but to 



CLASSIFICATION AND PREPARATION OF CAVITIES. 133 

considerable extent and make the gingival margin of the filling 
sufficiently rootwise, we shall find that the gum will rapidly cover 
it in a healthy condition. ISTot only this, but in many cases the 
gum will creep so far cro^vnwise as to cover the neck of the tooth 
and filling far in excess of its position before the operation. It ap- 
parently takes more kindly to a smooth gold surface than it does to 
cementum which may be denuded, or to enamel which may be 
slightly roughened. Some extreme cases of this kind of gum- 
reproduction have been noted, particularly in cuspids, where the 
gum has been known to cover the gingival portion of a filling to 
the extent of two millimeters. Such results as these are suffi- 
ciently gratifying to reward the operator for the necessary expend!^ 
ture of energy, and the patient for the discomfort accompanying 
the ^\'ork. 

In Fig. 66 will be seen a central incisor, with the cavity a pene- 
trating through the enamel, h defective enamel extending from 
cavity, and c the proper outline of filling. 

The cavity-ivalls. The plan of anchorage for these fillings is 

exceedingly simple. There is no need for the deep undercutting 

sometimes resorted to by operators, all that is necessary being to 

give a mortised form to the cavity by making the axial wall flat 

Fig. 66. Fig. 67. Fig. 08. Fig. 69. 

"'I ' 
j 
ir/ 




and the surrounding walls at right angles to it. At two points in 
the cavity it is well to make a slight dovetail to more securely lock 
the filling into place, viz, at the mesial and distal extremities. To 
this end the axial wall should be made slightly wider mesio-distally 
than the orifice of the cavity at the dentinal enamel-margin. Thia 
is especially true where amalgam is to be used on the buccal or 
lingual surfaces of molars. Amalgam requires broader and deeper 
anchorages to hold it in place than does gold, and this fact should 
be noted particularly in those cases on molars where the cavity 



134 PEINCIPLES AND PRACTICE OF PILLING TEETH. 

passes so far mesially and distally as to curve somewliat toward 
the proximal surfaces. These are the cases where amalgam is so 
often seen to curl away from the cavity at the extremities, admit- 
ting a leak around the filling. If amalgam is to be held securely 
in position in buccal or lingual cavities, it must be placed in broad, 
dovetailed anchorages. 

Technique. — In many of these cavities it will be found that 
while the enamel is completely disintegrated and dissolved away, 
the dentine maintains practically its original form, being simply 
softened or decalcified for considerable depth without breaking 
down. This softened mass of dentine is best removed with a 
hatchet excavator, the blade of which is thin, delicate, and ex- 
ceedingly sharp. The keen edge of the blade is placed on end at 
one extremity of the cavity and forced to the full depth of the 
decay. Then by a dextrous turn the whole carious mass is rolled 
out of the cavity in one piece, thus removing at a single sweep what 
is ordinarily the most sensitive portion of the tissue. This, if done 
skillfully, is usually not a very painful proceeding, but there must 
be no half measures about it. Any picking or manipulation of 
the carious mass bit by bit is simply excruciating as well as ineffec- 
tive. The operator should be at the same time gentle and thor- 
ough. His touch should be delicate and forceful, his movements 
definite and rapid. 

When the softened dentine is removed with the excavator the 
next step is to give form to the walls. This is best done with an 
inverted cone bur stood with its end against the axial wall, Fig. 
67, and carried mesially and distally across the cavity till the de- 
sired form is obtained. This kind of bur gives the proper shape 
to the walls and leaves a mortised effect, as shown in Eig. 68. As 
the bur approaches the mesial and distal walls of the cavity it 
should be carried somewhat into these walls to give a dovetailed 
form, as illustrated in the cross-section of an incisor. Fig. 69. In 
posterior teeth inaccessible to the straight hand-piece the desired 
result may be attained by using an inverted cone bur in the right- 
angle hand-piece. 

When the walls are formed the enamel-margins may be beveled 



CLASSIFICATION AND PREPARATION OF CAVITIES. 135 

"^ath a sharp chisel, or, what is preferable when properly used, a 
round bur in the engine. This must be kept under perfect control 
and made to follow the margin without slipping out of place. To 
maintain a bur in its proper position in following the margins of a 
cavitv it is often advisable to let the shank rest on a support or 
fulcrum formed by some adjacent surface of the enamel. In this 
way the bur may be accurately guided along the margin so as to 
cut at any desired angle. A more perfect symmetry may be given 
to a margin with a revolving instrument like a bur than is possible 
with a chisel. This is particularly true of the curves in the cavity 
outline. 

General Considerations. 

As has been stated, these cavities are often the most dreaded of 
any by the majority of operators. That they present elements of 
difficulty peculiar to themselves is undoubtedly true, but if treated 
on correct principles they are in many respects the most satis- 
factory of all filling-operations. The problem of anchorage is 
exceedingly simple on account of the lack of any stress tending to 
dislodge the filling. The marginal outlines of the cavity, if prop- 
erly formed, are comparatively safe from recurrence of decay, 
through the fact that the gum completely protects the gingival 
margin and the other margins are kept clean by friction of the 
cheeks, lips, or tongue. The open aspect of these cavities admits 
of an accurate placing of the gold and a close scrutiny of the mar- 
gins to detect and correct any imperfections. 

The chief difficulties of management relate to forcing the gum 
out of the Avay sufficiently to admit of free working, to keeping the 
cavity dry, and to the supposed fact that these cavities are usually 
more sensitive than others. As to the latter complication, it is 
counterbalanced both for the patient and operator by the rapidity 
with which such a cavity can be prepared, and the discomfort in 
the aggregate is therefore not much greater than with other cavi- 
ties of similar extent. 1'he problem of managing the gum and 
keeping the cavity dry is simply a question of skill and "knack" 
which may be acquired by almost any operator who will give a 



136 PKINCIPLES AND PRACTICE OF FILLING TEETH. 

close study to the special requirements of the case. With this 
skill once developed these cavities are readily brought under con- 
trol. 

Occlusal Cavities in Bicuspids and Molars. 

These cavities are usually the result of structural imperfections 
in the tooth by which the developing islands of calcification, begin- 
ning at the tips of the cusps, have failed to properly unite on 
approaching each other, leaving a leak for the ingress of foreign 
matter. The chief considerations in the management of these 
cases relate to the breaking down of overhanging enamel, the 
removal of decay, the obliteration of any remaining structural im- 
perfections in the way of fissures extending from the cavity, and 
the proper retentive form for the filling. 

An important distinction between caries occurring upon these 
surfaces and that of other surfaces already considered is due to the 
fact that upon occlusal surfaces decay seldom occurs except as the 
result of defects in the enamel, while on the others it is often found 
beginning upon perfectly formed enamel. The reason for this is 
that the friction of mastication very largely prevents the possibility 
of decay upon the occlusal surfaces, except as the agent of caries 
is harbored in some crevice or fissure where the cleansing process 
of mastication cannot reach. On this account extension for pre- 
vention is seldom indicated in occlusal surfaces unless the drilling 
out of all fissures running from the cavity may be so interpreted. 

This problem of the treatment of fissures is one indissolubly 
linked with the management of these occlusal cavities. Many 
operators do not seem to consider it necessary to drill out fissures 
unless actual decay has begun in them. They overlook two 
things, — the difiiculty of making a good margin to the filling at 
the intersection of a fissure, and the real nature of the imperfection 
that a fissure represents. If an operator has any doubt as to the 
necessity for drilling out all fissures extending from a cavity under 
preparation, let him make a microscopical examination of sections 
of teeth cut crosswise of a fissure, and he will no longer hesitate. 
In many of these cases where the orifice of the fissure is so narrow 



CLASSIFICATIOX AlfD PREPAEATIOK^ OF CAVITIES. 137 

as scarcely to admit the finest exploring instrument, the micro- 
scope will show a decided imperfection reaching entirely through 
the enamel, as indicated in Fig. 70. This kind of a break in the 
enamel-surface is a serious menace to the tooth, and no operator is 
doing his duty by the patient when he leaves such a defect in con- 
nection with his work. It is the minutiae which count in dental 
practice, and microscopic conditions must not be ignored. 

It would be a revelation to many operators to turn the micro- 
scope upon cases similar to the ones they are treating every day, 
and see the numberless imperfections which the unaided eye can- 
not detect. One of these fissures, apparently so slight as to be of 
little moment, and which the blunt exploring instruments in com- 
mon use in offices "udll scarcely penetrate, may be found large 

Fig. 70. Fir.. 71. Fig. 72. Fig. 73. Fig. 74. 




enough on microscopical examination to admit a whole army of 
micro-organisms sufficient, if the conditions be favorable, to under- 
mine the tissue in a few months. If we are to successfully combat 
this disease of dental caries we must be observant and infinitely 
painstaking. 

Another reason for drilling out these fissures and filling them is 
because the surface of the tooth is thereby rendered more perfect 
in form. In almost every case where a fissure exists there will be 
found a somewhat notable depression in the enamel leading down 
to it, and this V-shaped sulcus furnishes a receptacle for the lodg- 
ment of certain kinds of food material, to the annoyance and dis- 
comfort of the patient. Berry seeds and other like substances are 
especially prone to lodge in these depressions, and comfortable 
mastication is thus interfered with. It should be the office of the 
dentist to correct, if possible, any faults of form in the teeth he is 
operating on, and this may readily be done in the case of fissures 
by drilling them out and building up the filling as illustrated in 



138 PRIiVCIPLES AND PRACTICE OF FILLINCt TEETH. 

Fig. 71. This change in the form of the occlusal surface does not 
in any way detract from the efficiency of mastication, because the 
biting force of the cusps of the opposing tooth will be fully as 
effective — if not more effective — when exerted against a moderate 
concavity such as the surface of the filling would present, as it vnll 
when brought to bear upon a V-shaped depression. 

In what has been said with reference to drilling-out fissures the 
caution should be urged against confusing grooves with fissures. 
There is a sharp distinction between a groove which merely dips 
slightly into the surface of the enamel without penetrating it to 
the dentine, and a fissure which results in a complete cleft in the 
enamel. The groove may be safely left except in those cases 
where the depression would interfere with a perfect margin to 
the filling. 

The marginal outlines. The outlines of the different cavities 
in the occlusal surfaces will vary greatly according to the kind of 
tooth and the particular conditions present in each case. The 
number of cusps and the direction of the fissures seem to be the 
most prominent factors in determining cavity outline, while the 
extent of decay is of course always to be reckoned with. What 
may be considered typical cavity outlines are here illustrated in the 
different teeth. Fig. 72 shows the occlusal surface of an upper 
bicuspid with filling in place. This is almost universally the form 
for these teeth where the slightest decay has begun upon the sur- 
face, even if only one pit at the termination of the central groove 
has been affected. The reason for this is that the groove is nearly 
always fissured throughout its length, and even when not fissured 
it is sufficiently sulcate to prevent the proper finish of a filling 
against its intersection. In lower bicuspids — particularly in the 
first — the transverse ridge of enamel leading from the buccal cusp 
to the lingual is often so prominent and so perfect in structure 
as to leave no central groove, thus dividing definitely the mesial 
and distal pits. In these cases the pits may be filled separately, as 
illustrated in Fig. 73. In the lower second bicuspid the outline 
may sometimes simulate that of the upper bicuspids, while in occa- 
sional cases we find three cusps on this surface, necessitating the 



CLASSIFICATION AND PREPARATION OF CAVITIES. 



139 



outline given in Fig. 74. In the upper molars there are usually 
two cavities corresponding to the central and distal pits, as shown 
in rig. 75, or the disto-lingual groove may be fissured throughout 
its length, resulting in an outline such as that in Fig. 76. In cases 
of extensive decay, where the oblique ridge of enamel between the 
central and distal pits is so seriously undermined as to jeopardize 
its stability, it should be cut away and a cavity formed like the one 
in Fig. 77. 

It is sometimes a point of nice distinction to determine whether 
this ridge shall be left standing or be broken down, the decision 
being based principally upon two factors, — the extent of dentine 
supporting it and the depth of the distal groove. If it is not well 
supported by dentine it will prove an element of weakness between 
the two fillings, and if the groove is sufficiently deep to present a 
notable depression at this point it will leave an undesirable form to 



Fig. 75. 



Fig. 76. 



Fig. 77. 



Fig. 78. 




the surface. The operator must decide on the basis of long-con- 
tinued usage in the future rather than from past usage or a tem- 
porary service. One condition in this connection is calculated to 
mislead an unobservant operator, and this holds true as well of 
other walls on the occlusal surfaces as of the one under considera- 
tion. The fact that a certain wall has stood without fracture up 
to the time of the operation is often accepted as an indication that 
it may safely be left around a filling. The argument is used that 
if it has not broken when surrounding a cavity it certainly will 
not break when reinforced by a filling, but an important factor in 
the case is overlooked. When a tooth begins to decay it is often 
more or less sensitive under mastication, and the patient involun- 
tarily forms the habit of favoring the tooth so that it does not 
receive its full share of masticating usage. The decay progresses 
till the enamel is so undermined as to leave very weak walls, which 
may stand indefinitely under these conditions, so far as the stress 



140 



PRINCIPLES AND PRACTICE OF FILLING TEETH. 



of mastication is concerned. But when the cavity is filled and the 
tooth rendered comfortable, the patient gradually begins to use it 
again, and the consequence is, often, fractured walls when the 
operator had judged them to be safe. The highest class of service 
to our patients demands the closest insight into all of the factors 
making for or against the success of our operations. 

The cavity outlines on lower molars differ from those on upper 
molars, and there is also a variation between the lower first molar 
and lower second molar. The lower first molar has five cusps 
intersected by grooves which are frequently fissured, thus resulting 
in a cavity outline such as is illustrated in Fig. 78. Occasion- 
ally the buccal groove and the disto-buccal groove are fissured 
throughout their length, which would result in the filling being 



Fig. 79. 



Fig. 80. 



Fig. 81. 



Fig. 82. 



1 





carried over on the buccal surface to the full extent of the fissure. 
When this is done the buccal extremity of the cavity should pre- 
sent the form in Fig. T9. The lower second molar, having four 
cusps, calls for a cavity outline similar to that in Fig. 80. The 
third molars, upper and lower, are so variable in form as to pre- 
clude the possibility of suggesting anything like a uniform cavity 
outline in either of them, each case calling for special consideration 
as' it presents itself. 

The cavity-walls. The walls surrounding these cavities should 
be perpendicular, or in line with the long axis of the tooth. The 
pulpal wall or seat should be horizontal or flat, and should join the 
other walls at right angles. (Fig. 81.) This is particularly true 
of the mesial, distal, buccal, and lingual extremities of the cavity. 
On account of the difficulty of making a perpendicular wall at the 
termination of a fissure, the cavity extremities are sometimes left 
as illustrated in Fig. 82, a. This is an incorrect form, no matter 



CLASSIFICATION AND PREPARATION OF CAVITIES. 141 

how well the filling may be anchored in other parts of the cavity. 
In every case it should be formed as in Fig. 82, h. The reason for 
this is that the extremities of the fillings formed like that at a are 
likely to be lifted out of place in the mastication of adhesive mate- 
rials such as candies, etc. 

The depth of the cavity pulpally is governed in the carious por- 
tion by the extent of decay, and in the fissured portions by the 
depth of the fissure. It will be found that anything short of a 
full extension to the depth of the fissure will result in so shallow a 
cavity as to render the filling-material weak. ISTumerous failures 
of portions of these fillings along fissures have been noted in con- 
sequence of insufiicient bulk of material. There can be no argu- 
ment against deepening the cavity to the full extent of the fissure 
from the fact, as already stated, that wherever a fissure exists there 
is no binding strength to the tooth throughout its extent. The 
certainty of determining definitely just when the bottom of a 
fissure is reached is sometimes rendered difficult on account of the 
fine particles of tooth-tissue from the drill filling the deepest por- 
tion of the fissure and hiding it from view. This may readily be 
overcome by flooding the cavity with one of the essential oils, 
which will cause the fissure to immediately show up dark and pre- 
sent its entire outline. 

The width of the cavity bucco-lingually or mesio-distally in the 
decayed portion must be great enough to insure strong, well-sup- 
ported walls, while in the fissured portion it must be governed 
somewhat by the extent of the sulcus leading down to the fissure. 
The minimum width in any case should be not less than one and 
one-half millimeters. The mistake of leaving too narrow a cavity 
relates to the difiiculty of readily securing adaptation and density 
of gold in a constricted crevice, besides the important factor of 
providing for a sufficient bulk of filling-material to represent con- 
siderable strength on all surfaces which are subjected to continued 
usage. 

Technique.- — All overhanging walls may be broken down with 
sharp chisels, and the fissures opened with drills as already de- 
scribed. The cavity may be cut to form with an inverted cone bur 



142 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

placed with its end looking toward tlie pulp and carried laterally 
to the extent required. In cases diiiicult of approach with the 
straight hand-piece, — ^particularly on the lower teeth and the upper 
teeth of the left side, — the bur may be used in the right-angle hand- 
piece. Where the decay is extensive the softened dentine should 
be removed with spoon excavators to avoid unnecessary pulp-ex- 
posure. The enamel margins may be beveled with a round bur. 
These cavities are cut to form very expeditiously, provided the 
operator uses sharp burs and goes straight to his work with a defi- 
nite idea in his mind as to the required outline and form of the 
cavity before he begins cutting. 

General Considerations. 

Of all filling-operations in the mouth these should prove the 
most permanent and satisfactory if properly performed. There is 
little likelihood of a recurrence of decay around such fillings unless 
the operator has left imperfections in his work which would invite 
failure under any circumstances. The wear and tear upon occlusal 
fillings is sometimes great, but it is confidently believed that with 
the plan of anchorage here outlined ample provision is made for 
sustaining the filling against severe usage. The flat base to the 
cavity secures immunity from movement, and the perpendicular 
walls leave no overhanging enamel to be broken down. The 
obliteration of fissures results in improved form to the surface and 
precludes the possibility of micro-organisms finding a habitat in 
this region. Operations here as elsewhere must be carefully 
planned and executed throughout, but the results on occlusal sur- 
faces are never so much in doubt as they would seem to be in other 
localities. 

The Treatment of Softened Dentine in Deep-Seated Cavities. 

In the preparation of cavities the operator often encounters a 
problem in the presence of a large mass of decalcified or partially 
decalcified dentine in the bottom of a cavity lying over the pulp. 
The treatment of this softened dentine is a subject that has long 
engaged the attention of operators and writers on dental topics. 



CLASSIFICATION ANB PREPARATION OF CAVITIES. 143 

and the consensus of opinion seems in the past to have been favor- 
able to the retention of a considerable portion of the decalcified 
tissue for the purpose, as stated, of affording protection to the 
pulp. It has been argued that the pulp will accept more kindly 
this sort of protection than it will the presence of any foreign 
material in the nature of filling or pulp-capping. Some writer.'? 
have even advanced the theory that the softened dentine would 
take on a hardening process and become recalcified when left in the 
cavity under these conditions, and protected from further external 
irritation by a filling. 

Without stopping to go into the histological process of tooth- 
building and the pathological process of tooth-disintegration, it is 
safe to assume that tooth-tissue is not amenable to any such a law 
as would account for the recalcification of dentine once decalcified, 
and the sooner this idea is dismissed from the minds of our opera- 
tors the better it will be for their patients. From the closest clini- 
cal observation of thoughtful men, and from recent investigations 
into the penetrating effects of caries of the teeth, it would seem to 
be a serious menace to leave any considerable quantity of decalci- 
fied dentine under a filling. Miller has shown that the tubuli of 
dentine are packed with micro-organisms far in advance of the 
actual breaking down of the tissue, and, more re- 
cently. Dr. J. Leon Williams has presented to us a 
revelation in the far-reaching effects of caries. On .- 
page 289 of the Dental Cosmos for April, 1897, ha I - ZW\^ 
presents a photograph of which Fig. 83 is a fair repre- j 

sentation, showing how a tooth may be affected by y 

the acid of caries to a depth beyond the enamel, A 

and reaching very nearly to the pulp without any 
serious surface indication. The tooth was one in 
which "there was not a trace of a cavity to be seen on the external 
surface." Presumably an exploring instrument might have been 
passed over the enamel without detecting any imperfection, and 
yet the acid formed by the mass of micro-organisms lodged upon 
the surface had so affected the tooth-tissue as to dissolve out the 
cement-substance between the rods of enamel, leaving minute 



144 PKIISrCIPLES AND PRACTICE OF FILLING TEETH. 

canals down which the acid traveled to form a perceptible cavity at 
the junction of the enamel and dentine, and also to extend its soft- 
ening influence some distance into the dentine in the direction of 
the pulp. 

Here is an object lesson to set even the most careless operator to 
thinking. If the acid of decay may affect tissue to the depth indi- 
cated without any perceptible external evidence, what must be the 
condition of the dentine covering the pulp when the process of de- 
cay has gone on so far as to cause a complete disintegration of the 
enamel and an extensive cavity into the dentine? We can no 
longer trifle with a disease which projects its baneful influence so 
far in advance of any ocular manifestation. 

Let us study briefly the nature of this decalcifled tissue which 
we are taught to leave under our fillings. It has in large part 
been disorganized; it is packed with micro-organisms and infil- 
trated with poisons. If we seal it under a filling we have confined 
within the tooth just so much of a menace to the life and comfort 
of the pulp., It will not do to say that the micro-organisms thus 
inclosed are rendered harmless on account of cutting off their out- 
side sustenance and allowing them to die. A mass of dead micro- 
organisms is by no means inert. In fact, scientists are telling us 
that from the dead bodies of micro-organisms come the most viru- 
lent poisons. Neither will it do to assume that by the application 
of an antiseptic to the cavity w^e overcome the difliculty. We may 
destroy more or less perfectly the micro-organisms in the dentine, 
but we are not at all certain of thereby destroying the poisons. 
In experimental work micro-organisms are killed with chemical 
agents, and then from the mass thus destroyed the poisons are 
extracted. It would seem to be a fruitful field of research for some 
scientist to determine the kind of agent required to destroy the 
micro-organism and at the same time neutralize its poison. 

But what concerns us most in the consideration of the present 
subject is that by following the generally accepted teaching of the 
day in the management of decalcified dentine we are simply confin- 
ing in intimate proximity to the pulp a mass of material which is 
peculiarly calculated to poison the pulp to death. And this is 



CLASSIFICATION ANT) PKEPAKATION OF CAVITIES. 145 

precisely what occurs in many of those vague cases where the 
pulp has "unaccountably" died under a filling without an exposure. 
The greatest surprise is that more pulps have not died from this 
treatment, and it is accounted for only on the ground that pulps 
are sometimes exceedingly tenacious of life, and protect them- 
selves against the inroads of the poisonous process by throwing 
out a deposit of secondary dentine. Even in those cases where the 
pulp finally triumphs over the evil infiuence, the operation of fill- 
ing is quite frequently succeeded by an extended period of sensi- 
tiveness which is the direct result of the irritating influence of the 
infiltrated dentine. In almost every instance where softened den- 
tine is left in the cavity as a source of pulp protection, or to prevent 
shock from thermal changes, it defeats the very object for which it 
was left. This mass of tissue is exceedingly irritable. It is more 
sensitive to impressions of all kinds, whether thermal, chemical, or 
mechanical, than is normal dentine. It would therefore seem 
theoretically that the less we left of this infected tissue under a 
filling the more comfortable would the tooth remain after the 
operation, and this very fact is amply borne out by clinical observa- 
tion. In a somewhat close study of this question it has been noted 
that in those cases where a radical removal of all softened dentine 
has been effected there is seldom any complaint of subsequent 
sensitiveness. 

This does not imply that we must carelessly expose pulps by 
wantonly slashing away at every cavity that presents. ISTo opera- 
tor should expose a pulp if it can be safely avoided. In working 
around a pulp under these conditions, as has already been inti- 
mated, a spoon-shaped excavator should be used to avoid needless 
exposure. The excavator should be very thin and sharp, so as to 
peel up the leathery dentine with the utmost delicacy and the ex- 
penditure of very little force. 

The rules to govern the operator in the management of decalci- 
fied dentine may be summarized as follows: Remove thoroughly 
all decalcified tissue in every instance where its removal will not 
result in exposure of the pulp. In those cases where it extends to 
the pulp remove all that can safely be done short of actual ex- 

10 



146 PKINCIPLES AND PRACTICE OF FILLING TEETH. 

posure, and, if large masses of decomposing tissue surround any 
portion of tlie pulp, remove even if it causes exposure. The pulp 
will be safer under a capping of foreign material than when sub- 
jected to the influence of this infected and poisonous mass. 
Stained dentine is not necessarily infected dentine. If hard and 
flint-like it may be allowed to remain, even if slightly discolored. 
While the exact results of the application of medicaments to 
decalcified dentine may be as yet somewhat undetermined, it would 
seem, with our present knowledge on the subject, to be a wise 
precaution to flood all cavities containing any such tissue with an 
antiseptic previous to filling. We must also protect the pulp from 
impingement in those cases where the partition between the cavity 
and the pulp is so thin as to be compressible under the force of 
impact by the plugger in condensing a metal filling, or where there 
seems to be danger from thermal impressions. For this purpose 
a non-irritating cement is indicated as an intermediate between the 
filling and the pulpal wall, but this cement must not be built up in 
such bulk as to render the metal filling too thin for strength. 

Hypersensitive Dentine. 

This is a subject which has been more or less prominently before 
the profession ever since teeth began to be filled, and yet it would 
sometimes seem to be little nearer a solution of the problem than 
when it was first discussed. This is partly because there are so 
many varying aspects of the question, and because no sovereign or 
universal remedy can ever be suggested by which uniform results 
may be obtained; but possibly, more than all else, because the very 
thing most essential to success in meeting the trouble is something 
that cannot well be taught. It relates to a quick perception on 
the part of the operator as to the real difiiculty with each case 
which presents, and to the most active ingenuity in meeting the 
particular issue involved. In many instances it would seem to be 
the dentist who needed treatment instead of the dentine. In 
others the patient requires operating on in advance of the tooth. 

To present this subject in anything approaching a systematic 
order, it will be necessary to classify somewhat the conditions 



CLASSIFICATIOI!^ AND PKEPABATION OF CAVITIES. 147 

which may confront the operator. These conditions relate to the 
varying temperaments of patients, and to the differences in char- 
acter of sensitive teeth. Patients require the closest study in order 
to know how best to approach them to dispel the common dread of 
the dental chair, and no operator is suited to the practice of den- 
tistry who ignores this important feature of his work. It has been 
too long a crying disgrace to dentistry to permit the impression to 
prevail among all classes that dental operations are necessarily so 
very painful. Some of the old-time heroic operators (blessed be 
their memory) are, in this one particular, blamable that they too 
often entirely ignored the sensibilities of their patients, and treated 
them as if they were mere blocks of wood. We of to-day are reap- 
ing the results of some of this early sowing in the almost universal 
dread with which patients approach the dental chair, owing largely 
to the traditional story of its tortures. In the modern dental prac- 
tice, properly conducted, there is little to justify this dread, and 
the dentists of to-day should do all in their power to overcome the 
impressions formed by past years of mismanagement. 

In studying the characteristics of our patients in this regard it 
might be possible to make many minute classifications as to con- 
duct and temperament, but for present purposes a more general 
consideration must suffice. 

First as a class may be noted those of a highly-wrought, nervous 
temperament, who are by nature sensitive to impressions of all 
kinds, whether physical or mental. This, when augmented by 
environment or occupation, creates a condition which calls for the 
keenest perception on the part of the dentist, both as to manage- 
ment of the patient and manipulation of the teeth. They are 
usually professional men or women, — artists, musicians, sculptors, 
or literary people, — and, fortunately for us, they are generally indi- 
viduals of a high order of intelligence. They are quick in their 
perceptions and are appreciative of skillful service. ISTo dentist of 
mediocre attainments need hope for an extended practice among 
this class, and yet, if managed by a master hand, they prove a most 
desirable dieniele. The essentials in meeting these patients relate 
to a thorough mastery of the minutest details of the work in hand, 



148 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

and a quiet but rapid execution of all manipulative procedures. 
There must be no false movements, and no lapses of the closest 
application. To accomplish the greatest good all work must be 
done on the high-pressure principle. A patient like this will bear 
to be hurt for one short moment provided something definite be 
accomplished in that moment, but will not tolerate unskillful put- 
tering. Every line of procedure must be carefully studied by the 
operator in advance, so that he knows precisely what he is going 
to do before he attempts to do it. Any awkward fumbling in the 
manipulation is instantly recognized by the patient, and confidence 
is to that extent destroyed. The utmost delicacy of touch should 
be cultivated, and this complemented by firmness of force wherever 
force is indicated. Short sittings must be assigned, and the great- 
est possible measure of accomplishment attained during the time 
the chair is occupied. In brief, this type of individual demands 
of a dentist the exercise of his keenest wits, and to operate to 
the best advantage he must operate on a tension keyed to the 
highest pitch. It is therefore well that all our patrons are not 
of this variety, and yet, as has been intimated, they prove a savor- 
ing lump to the rank and file and are in many ways a desirable 
class. They stimulate an operator to his best achievements, and 
reward him with an intelligent appreciation of all that he accom- 
plishes for them. 

Another class of patients consist of large, robust, healthy indi- 
viduals who are by nature cowardly when it comes to the infliction 
of physical discomfort. They may be brave enough about other 
affairs of life, but it would sometimes seem that the larger they are 
in physical proportions the smaller they are in courage to take the 
dental chair. There is no moral suasion that can be used on these 
people to make good patients of them. The only line of procedure 
is to avoid as far as possible giving pain by the use of obtundents, 
or by employing plastic fillings and temporizing to keep the teeth 
comfortable, with the hope that eventually we may in some degree 
overcome their dread sufiiciently to accomplish more permanent 
results. If we undertake anything like thorough work at the out- 
set we simply drive them away from the dental office to allow the 



CLASSIFICATION AND PREPARATION OF CAVITIES. 149 

teeth to decay past all recovery. Then when toothache assails 
them they seek ont some dentist who gives gas, and that is the end 
of that chapter. 

Another class relates to those effeminate, irresponsible indi- 
viduals who have no stamina of any kind, physical or mental, and 
who require a strong guiding hand to control them in any emer- 
gency of life. They are usually forced to go to the dentist either 
by pain or by the admonition of friends, and their successful man- 
agement calls for a rare combination of gentleness and firmness. 
They must of course be assured that the dentist will not hurt 
them more than is absolutely necessary, but they should also be 
given to understand that they must nerve themselves against any 
pain that is necessary. A dentist should never be harsh with any 
patient, but with this particular class it is sometimes salutary to be 
stern and to permit of no trifling. If much sternness is demanded 
during an operation, it should invariably be tempered before the 
patient vacates the chair with the kindest possible tone of voice, to 
the end that the patient leaves the office with the conviction that 
the dentist is kind of heart and is severe only for the patient's good. 
A series of dental operations for an individual of this type often 
proves of the utmost disciplinary benefit, provided the operator is 
an acute reader of character and knows just when to be firm and 
when to be gentle. 

He should be quick to detect the difference between simulated 
pain and real pain, from the fact that these patients are much given 
to protesting even when there is no occasion for it. A simple 
pressure of an excavator on the enamel of a sound tooth is as 
likely to cause them to flinch as if a mass of sensitive dentine were 
being removed, and no self-respecting operator will long allow 
himself to be made the victim of this kind of folly. He should 
have the issue out with them immediately on the detection of such 
imposition, and give them to understand that he is neither to be 
deceived nor trifled with. But the moment it becomes necessary 
to give real pain he should be the very essence of gentleness and 
forbearance, and do all in his power to help the patient over the 
painful points. In this way he will not only prevent imposition in 



150 PEIlSrCIPLES AND PEACTICE OF FILLING TEETH. 

the future, but will establish confidence in the mind of the patient 
that he is solicitous only for his patron's welfare. Absolute 
honesty of conviction and conduct, together with tact in its fulfill- 
ment, is the keynote of success with these, as in fact with all other 
patients. 

The management of children in the dental office is another con- 
sideration worthy of the closest study. A child never should be 
given pain if possible on the occasion of its first visit to the dentist. 
In fact, the infliction of pain should be as largely avoided as may 
be till a feeling of harmony and confidence has been established 
between the little patient and the operator. A child should be 
received in the operating-room with a cheery smile, as if the 
affairs of the world were very bright on that particular occasion, 
and that a visit to the dental office was not such a terribly serious 
thing after all. Unfortunately, children usually come to the den- 
tist with more or less apprehension, owing to the traditional table 
talk about the horrors of the dental chair. It is the prime function 
of the dentist to dispel this idea, and he who has kindness, tact, 
and good judgment can work wonders in this direction on that 
momentous first visit. But he must have a love of children in- 
herent in his heart or he cannot hope to succeed. He who does 
not love children would better direct them to some one who does, 
because of a certainty they will prove a constant source of annoy- 
ance to him, and he will accomplish little else with them than to 
increase their dread and distaste of dental operations. 

A child should never be deceived by a dentist under any pretext 
whatever, and yet it is not well to make prominent the fact that it 
is going to be necessary to inflict pain. The dentist should lead 
gradually up to any painful operation by a series of dextrous and 
careful manipulations about the teeth, and a running talk with the 
patient upon the contingencies of the case from a child's point of 
view. The thing of first importance is to establish confident 
and cordial relations with the patient, and when this is once at- 
tained the operator can accomplish really wonderful results, even 
upon the youngest child. Tact, kindness, the alleviation of pain 
when the patient is suffering, lack of deception, and short sit- 



CLASSIFICATION AND PEEPARATION OF CAVITIES. 151 

tings, all harmonize into the successful management of children's 
teeth. 

If the control of the different classes of patients herein briefly 
outlined is studied, the problem of the sensitive dentine is many de- 
grees more than half solved; in fact, it would sometimes seem as if 
this bugbear were greatly exaggerated by the profession. A care- 
ful observation of the causes which lead the average patient of 
to-day to dread the dental chair in a properly conducted practice 
will reveal the fact that it is as much the concomitant annoyances 
of the rubber dam, the separator, the mallet, the use of disks or 
finishing strips, the grating of excavators, or the vibration of rotary 
instruments, as it is the infliction of any real pain in the cutting of 
sensitive dentine. And yet there are many unmistakable cases 
of actual hypersensitiveness that must be recognized and dealt 
with. 

The treatment of these cases relates to proper instrumentation 
and proper medication, — the former fully as important as the 
latter. The dextrous use of instruments will reduce the number of 
cases requiring medication to a very narrow limit, and it is strongly 
urged that a most careful study be made of the manner of ap- 
proaching hypersensitive dentine so as to remove it with the least 
possible discomfort. 

Cavities may be divided more or less perfectly into classes, each 
class presenting its own peculiarities of sensitiveness, and suggest- 
ing the method of treatment best suited for it. A large class con- 
sists of those cases where there is a mass of softened dentine nearly 
filling the cavity, with much overhanging enamel. If an instru- 
ment is thrust into this leathery mass at almost any point it is sensi- 
tive. If there is any manipulation of it along the surface it gives 
pain. The first thing to do is to break down all overhanging 
enamel, so that the dentine lies as fully exposed as may be before 
any attempt is made to remove it. Then, with a thin-bladed exca- 
vator, whetted keenly sharp, the whole mass should be removed as 
completely as possible with one sweep. This can ordinarily be 
done with little pain if the blade of the excavator be sunk at one 
bide of the leathery mass to its depth, and the mass rolled out. 



152 PRmCIPLES AND PKACTICE OF FILLING ' TEETH. 

The tissue immediately under this softened layer is usually not so 
sensitive as the surface, and the remaining cutting to give form to 
the cavity is seldom appreciably painful. But, in case there is sen- 
sitiveness, it can be controlled by dehydrating the tissue vs^ith alco- 
hol, followed by v^arm air. If the rapid dehydration causes pain 
it should be preceded by ninety-five per cent, carbolic acid, after 
which the cavity can be dried with little discomfort. Dr. llT. S. 
Jenkins has suggested that carbolic acid to be most effective for 
relieving sensitiveness should be heated, and Dr. Geo. Gow recom- 
mends as the best means of heating it to pack the cavity with 
cotton saturated with the agent and apply to it a hot burnisher. 

In the application of any medicament to a cavity the fact should 
be made prominent to the patient that the drug is being used for 
the purpose of relieving the pain. This of itself reassures the pa- 
tient, and is often of more benefit in a psychological way than is 
the specific action of the drug. 

Another class of cavity calling for treatment peculiar to the 
case in hand consists of those shallow oval cavities, particularly on 
the labial or buccal surfaces, where there is little softened dentine, 
but merely a corroded and reasonably hard surface to the cavity. 
Most of the cutting, must be done in comparatively firm tissue, for 
the purpose of giving retentive form to the cavity and to secure 
perfect margins. These cavities are much dreaded by dentists on 
account of their traditional sensitiveness, but by a careful observa- 
tion it will be found that with very many of them the sensitiveness 
exists only on the surface. The first touch is the worst. If, when 
the rubber dam is applied and the cavity dried, the operator will 
take a sharp inverted cone bur, as already advised for forming 
these cavities, and, vdth the engine revolving rapidly, place the end 
of the bur in the deepest portion of the cavity, and just at that 
moment speak to the patient in a reassuring tone of voice, and 
while speaking at once penetrate this outer sensitive crust with 
the bur, the worst of that cavity preparation is over. The bur 
may then be carried laterally, its end to the full depth of the cavity 
and cutting with its sides, causing little pain. The active cutting 
in the deep portion of the cavity is less painful than would be the 



CLASSIFICATION AND PKEPAEATION OF CAVITIES. 153 

slightest manipulation on the surface. The surface should there- 
fore be left alone as largely as possible till the sides of the bur have 
undermined it in advance. In the successful management of these 
cases there must be no hesitation and no half measures. The 
operator must know definitely what he is going to do, and then do 
it with the greatest dispatch and precision. It requires a masterly, 
vigorous hand, wielded with the utmost delicacy. 

Sometimes the surface sensitiveness of these cavities may be 
greatly reduced by medication and desiccation. For this purpose 
carbolic acid, followed by alcohol evaporated with warm air, seems 
to give the best results with the least accompanying discomfort. 
The application of drugs which cause more pain on contact with 
the dentine than would the preparation of the cavity itself should 
be discontinued, unless for those exceptional individuals who seem 
to prefer any kind of pain rather than pain given by an instrument. 

With very many cavities it will be found that the sensitiveness 
is confined to one or two small areas, which if dextrously under- 
mined or cut through quickly will solve the problem in short order. 
When an operator discovers in a cavity one of these sensitive 
points he should avoid manipulating it, unless with a definite 
attempt at its complete removal. 

The last class of cavities for consideration relates to those occa- 
sional cases where the teeth are in an unmistakably hypersensitive 
condition, where the slightest pressure upon a cavity results in 
pain, and where anything like thorough manipulation is out of the 
question. There is one of two courses to pursue: either to numb 
the sensibilities of the tooth by cataphoresis, with all of its con- 
comitant paraphernalia, its consumption of time, its accidents, 
and its as yet undetermined ultimate results, or to employ as a 
temporary expedient till the sensitiveness subsides some filling- 
material such as cement, which may be used without the thorough 
preparation of the cavity required for the metals. 

Sometimes one course is indicated and sometimes the other, but 
in the large percentage of cases it will be found better to make use 
of temporary fillings to tide the teeth over the sensitiveness, rather 
than to follow the general employment of cataphoresis. 



154: PRINCIPLES AND PEACTICE OF FILLING TEETH. 

lu the use of cement for the sealing of cavities temporarily, as 
just advised, the common error is made of allowing it to remain 
too long, till it is so disintegrated as to defeat the object for which 
it was used. If a cement filling be placed in a very sensitive cavity 
so as to perfectly seal it from external irritants, and allowed to 
remain from three to four months, it will be found on removal that 
the cavity can be prepared properly with little pain. As much of 
the decay as possible should be removed from the cavity before the 
cement is inserted, and when the cement is to be drilled out the 
rubber dam should be applied and the cavity kept free from mois- 
ture till prepared as desired. In those cases where it seems impos- 
sible to remove the decay in the first instance it is often advantage- 
ous to seal a pledget of cotton saturated with the oil of cloves in the 
cavity for three or four days, when the decay can ordinarily be 
rolled out of the cavity with sharp excavators. 

The whole question of the management of sensitive dentine, 
except in the rare instances just indicated, resolves itself to the fol- 
lowing summary: Manipulative skill on the part of the operator, 
tact in knowing how to control the different temperaments among 
our patients, and the invariable use of the keenest, sharpest instru- 
ments. 



CHAPTER VI. 

EILLING-MATEKIALS. 



A PKOPEK consideration of the filling-materials in use at the 
present time leads us at once to the conviction that we have no 
ideal material with which to fill teeth. We have materials which 
answer the purpose reasonably well under certain conditions, but 
no material which answers well under all conditions. It is there- 
fore important that in the consideration of this question we study 
somewhat carefully the characteristics of the different materials 
and the indications for or against their use under the varying con- 
ditions found in the mouth. This must be done with the fact 
constantly in mind that no rigid or invariable rule may be laid 



FILLING-MATERIALS. 155 

down for the operator to follow in every case in the selection of his 
material. He must exercise his best judgment on the basis not 
only of expediency, but of the history of the various materials 
under long-continued service. 

Gold and Its Combinations. 

Of all the materials yet introduced for filling teeth, gold must 
be acknowledged the peer. When properly understood and prop- 
erly manipulated, under conditions favorable to its use, it is one 
of the most permanent materials we possess. It is imperious in 
its requirements, as are all things worthy, and he who would get 
the most from its use must adequately acquaint himself with its 
characteristics. These once understood, and the necessary skill 
developed to master the details of its manipulation, the operator is 
equipped with a material which is more reliable than any other, 
and more definite in results. 

Its chief advantages consist in the fact that it may be made suf- 
ficiently hard to withstand the wear of mastication; that it is not 
acted on chemically by the fluids of the mouth so as to change color 
or disintegrate; that it remains stationary in form when properly 
condensed, and that it is uniform in its behavior when subjected to 
uniform methods of manipulation. This latter quality is really of 
much greater importance than a superficial consideration would 
suggest. It enables the operator to attain with it definite results, 
year after year. It will do to-day precisely what it did the day 
before, or what it did a year ago. This is not true of most other 
filling-materials, or at least, if it is true, the requirements for main- 
taining uniformity in the others are vastly more intricate and not 
80 readily comprehended as with gold. 

When it is stated that uniform results may always be obtained 
with gold, reference is made solely to its physical behavior. It is 
not intended to imply that teeth are uniformly saved by its use, 
even when it is manipulated to the best advantage. There are ex- 
traneous factors entering into the salvation or loss of filled teeth 
entirely apart from the intrinsic merits of the material with which 
they are filled, and gold cannot be exempted from these conditions. 



156 PKINCIPLES AND Pit ACTIOS OF TILLING TEETH. 

But it has a greater range of qualities entitling it to respect as a 
saver of teeth than any other one material, and the thorough 
understanding of it should be the aim of every practitioner. 

Its disadvantages may be said to consist chiefly in the fact that 
it is somewhat exacting in its demands upon the operator; that it 
cannot be manipulated successfully under moisture; that its color 
renders it conspicuous for anterior teeth, particularly in individuals 
of certain types, and that it is a conductor of thermal changes. 
Another objection which must be considered in some patients is the 
length of time necessary for its insertion, with its corresponding 
tax on the individual, and its relative cost; though the fact should 
be strongly noted that a thorough mastery of the material by the 
operator will reduce much of this within the limits of tolerance. 

ISTor must the claim of its exacting nature be held in too high 
esteem as a disadvantage. This very requisite on the part of gold 
has done more than any other one thing in developing the skill of 
the dental profession to its present standard of excellence. Had it 
not been for gold, or, in other words, had all our filling-materials 
been of a plastic nature, dentistry never would have developed the 
brilliant manipulators who have graced its ranks. Gold is the 
stimulative astringent of the dental profession, keeping our opera- 
tors keyed up to the highest point of proficiency by reason of its 
imperious demands upon their ability. A good gold-worker ia 
enabled to perform all other kinds of dental service in a creditable 
manner as the result of his skill acquired in the manipulation of 
igold, and this sort of training has been the sa"^dng grace of 
dentistry. 

Too many sins which belonged properly elsewhere have been 
laid at the door of gold. Men have attempted its use without a 
sufficiently developed skill, or without a proper understanding of 
its necessities. They have ignored its physical properties and its 
peculiar demands. Other men have essayed with it the impossi- 
ble, and then attributed their failures to the material, thus laying 
gold unjustly at fault. 

The fact that gold cannot be successfully used under moisture is 
neither an unmixed evil nor altogether a disadvantage, when 



FILLING-MATERIALS. 157 

viewed in the light of the greatest perfection of results in our 
work. jSTo filling, of whatever material, can be inserted under 
moisture as perfectly as if the cavity were dry, and this necessity 
of gold simply increases our care and leads to greater certainty of 
results. It has also made us more expert in maintaining dryness 
of teeth to be operated on. 

The objection of color is a real one in many instances, and the 
vulgar display of gold in the mouths of the American people is 
greatly to be deplored. But this may largely be overcome, and the 
artistic sense of observers less seriously offended than it is without 
an abandonment of gold in the anterior teeth. A close study of 
the question will reveal the fact that gold is much more objection- 
able in some mouths than in others. In certain individuals a well- 
finished gold filling, beautifully polished without being burnished 
so as to glisten, is not at all conspicuous, even in an incisor, and not 
an offense to the esthetic taste of the most exacting. In other in- 
dividuals a gold filling in the anterior part of the mouth is at 
best an eyesore. 

The difference in the effect of gold upon the appearance of indi- 
viduals relates principally to the temperament and complexion of 
the patient, as well as to an esthetic sense on the part of the opera- 
tor, which may enable him to give his fillings artistic forms. The 
latter consideration should be carefully studied by every operator, 
to the end that gold fillings in the future should not be allowed to 
offend so glaringly as in the past, particularly in those instances 
where offense is not necessary. As to complexion, it will be found 
that decided blondes will tolerate gold in their anterior teeth with 
less objection than will brunettes. In fact, the color of gold har- 
monizes so well with the former that if the filling is well inserted 
there is nothing to offend the eye at a distance of several feet. 
On the other hand, a gold filling in the mouth of a brunette be- 
comes at once conspicuous and objectionable. It is completely 
out of harmony with the features, and should never be tolerated 
except under circumstances of the most urgent necessity. This 
necessity seldom exists, in view of the fact that we have a material 
at hand which makes a filling scarcely discernible in these cases at 



158 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

a distance of ordinary conversation. This relates to a combination 
of gold and platinnm which, under its proper head, will be con- 
sidered in detail. The various gradations from brunette to 
blonde may be met with gold and platinum by using the different 
numbers as they come to us from the manufacturer, so that fillings 
may be made which will not be conspicuous, and every operator 
should acquaint himself with this material. The recent perfection 
of porcelain inlay work also presents another method which prom- 
ises much in the way of artistic results for anterior teeth in those 
cases where gold is objectionable. 

The question of thermal influence under gold fillings has claimed 
much attention from the profession, and there has been a large 
degree of misconception concerning it. Gold has been credited 
with more mischief in this particular than its merits warrant; for, 
while the material itseK is a good conductor, it can be used in the 
mouth with little discomfort and little danger, provided proper 
precautions are taken. Gold is well tolerated even in large cavi- 
ties, if the pulp is not nearly exposed, or if there is not hyper- 
sensitiveness of the dentine. In the former case the pulp should 
be protected by an intermediate layer of cement before the gold 
is inserted, and in the latter case the hypersensitiveness should 
be controlled by medication previous to filling. Probably one of 
the best agents for this purpose is ninety-five per cent, carbolic 
acid. 

One important factor connected with this question of thermal 
trouble relates to a condition apart from the filling itself. In the 
past, the profession has been very generally advised to leave in the 
bottom of cavities of any extent a portion of decalcified dentine as 
a protection to the pulp, the fallacy of which has already been 
pointed out. Gold has frequently been severely censured when 
the chief factor at fault in the case has been the presence in the 
caAdty of a hypersensitive mass of decalcified tissue which should 
have been removed in the preparation of the cavity. 

If these precautions are taken, the trouble from thermal changes 
under a gold filling will be found for the most part temporary, 



FILLING-MATEEIALS. 159 

and not of such serious import as has usually been attributed 
to it. 

The indications for or against the use of gold in filling teeth 
relate to conditions most of which must be apparent to every ob- 
servant operator. It should be used in all cases, if possible, where 
the greatest utility and the greatest permanence are expected of the 
operation. It should not be used where the conditions are such 
that it is manifestly impossible to accomplish perfect work with it. 
The control of the patient, whether young or old, is a necessary 
concomitant to the successful use of gold. It should not be 
attempted with a patient upon whom the physical or nervous tax 
would be too great, nor should it be employed in a tooth the peri- 
dental membrane of which is so greatly impaired as to revolt 
seriously against the impact of the mallet. In short, the best 
judgment and the closest discrimination should be exercised to the 
end that this king of all filling-materials be not crucified by the 
enthusiastic umvisdom of its chief advocates. 

Combinations of Gold with Other Materials. 

Gold and Platinum. This material makes a harder filKn<'' 
and one capable of greater wear than gold alone. It is also — as 
has been indicated — possible to produce with it fillings of varying 
degrees of shade which may be made to harmonize agreeably with 
the different types of patients which come under our hands. 
These degrees of shade are regulated by the percentage of gold 
and platinum in the given product. One preparation contains more 
gold than platinum, another about equal parts, while a third has a 
preponderance of platinum, and the color is thereby affected so as 
to range from a decidedly yellomsh to a decidedly grayish tinge. 
This variation of the material may be used to striking advantage 
in harmonizing the filling with the features of the patient. The 
soft gray platinum shade falls in beautifully with the general 
effect in the mouth of a decided brunette, while the varying gra- 
dations from that to a light blonde may be followed with artistic 
results by a careful selection of the corresponding shades of ma- 
t<3rial. 



160 PKINCIPLES AND PEACTICE OF FILLING TEETH. 

The combination of gold and platinum should be employed to a 
greater extent by the profession than it is to-day, for, while its- 
manipulation is somewhat more exacting than that of gold, its in- 
telligent use will lead to artistic results not attainable with gold 
alone, and its superior density adds greater permanence to the sur- 
faces of all fillings which are in any way subject to attrition. Ita 
manipulation will be considered later. 

Oold and Tin. — This combination of materials possesses quali- 
ties which should commend it to the favorable attention of the pro- 
fession. If its limitations are understood and the cases carefully 
selected for its use, it will prove a source of great satisfaction both 
to patient and practitioner; and it is therefore worthy of sufficient 
merit to induce every operator to study its characteristics and 
master the details of its manipulation. The claim has been made 
that it possesses no ^drtues which may not be found in non-cohesive 
gold, but in two important particulars this would seem to be an 
error. The tin foil imparts to the mass a quality which non-cohe- 
sive gold does not possess, viz, a lead-like consistence which makes 
the product tougher and more readily adapted to walls of cavities. 
A plugger-point will not penetrate gold and tin so easily as it will 
a similar mass of non-cohesive gold; and another important item- 
is the fact that the filling will build up more rapidly under the 
plugger than will gold with equal manipulation. A filling of gold 
and tin may therefore be inserted in less time than a similarly 
condensed filling of gold. But probably the most important dif- 
ference between this combination and non-cohesive gold lies in 
the fact that in most instances, after a filling of gold and tin has- 
been inserted for a time, the material undergoes a change which 
renders it much harder than it originally was, or than non-cohe- 
sive gold can possibly be made. It becomes crystalline in char- 
acter, so that the filling is an integral mass, with little distinction 
between the gold and the tin. "When it is first inserted, it is easily 
picked apart; but after several years' service in the mouth it be- 
comes almost vitreous in nature, so that an excavator when drawn 
across it will respond with a metallic vibration. It has lost ita- 



FILLING-MATERIALS. 161 

dead softness and taken on a crystalline character which greatly 
increases its resisting properties and adds to its serviceability. 

Its limitations consist in the fact that it will discolor in the 
luouth, so that it cannot be used in any position where it may be 
seen, and also that it can never be built into contours or used in 
cavities of sufficiently large area to bring any considerable attrition 
of mastication upon it. The indications for its use relate princi- 
pally to occlusal cavities in molars and bicuspids for children, and 
along the gingival third of deep occluso-proximal cavities in molars 
and bicuspids where the main body of the filling is to be of gold. 
It is especially useful in this latter case on account of materially 
shortening the operation and avoiding any possibility of discomfort 
from thermal changes, owing to the reduced conductive properties 
of the tin in the combination. The rapidity with which it may be 
inserted renders it a very desirable material in the mouths of 
children, where the avoidance of the rubber dam is an important 
consideration. 

Gold and tin cannot be expected to do the same length of ser- 
vice as gold in any position where it is subjected to the constant 
attrition of mastication, and yet many of these occlusal fillings 
which have been under observation for ten or twelve years give 
every prospect of long-continued usefulness, — their length of ser- 
vice in most cases being out of all proportion to the limited time 
necessary for their insertion. 

Gold and Iridium. — This combination has gained little atten- 
tion from the jDrofession, nor has it much to recommend it as a 
filling-material. By its use a harder surface may be given a 
filling than is possible with gold, but on being finished it presents a 
brassy appearance not pleasing to the eye, and it is therefore 
applicable only to posterior teeth. Even in these cases there is 
seldom an instance where gold and platinum will not do equal 
service and present a more artistic effect. 

Amalgam. 

This material has been at once the refuge and despair of the 
dental profession. It has probably saved teeth that never would 
have been saved without it, but, even in the hands of its most 

11 



1G2 PETNCIPLES AND PRACTICE OF FILLING TEETH. 

enthusiastic advocates, it lias so often proved a disappointment that 
observant men can no longer remain blind to its limitations. The 
investigations of Fletcher, Flagg, Bogue, Black, Wedelstaedt, and 
others have thrown much light on its characteristics; but even Avith 
the most that has been learned of it, and the best that has been said 
of it, the fact remains that much of the amalgam now offered the 
profession is ill adapted to the permanent saving of teeth. ISTor 
are we likely soon to have in general use amalgams which may be 
uniformly depended upon, — not because a reasonably reliable 
grade of amalgam is impossible of manufacture, but because the 
conditions necessary to produce it are so exacting and the process 
so intricate that few men will be found sufficiently painstaking to 
invariably furnish it. 

The chief faults with amalgam, as presented to us in the past, 
have exhibited themselves in a tendency to compress under the 
impact of mastication, so as to be drawn away from the cavity- 
walls, but more particularly in a tendency to so change form, 
even after crystallization has taken place and where no undue 
pressure is exerted, as to produce a serious leak between the filling 
and the wall of the cavity. This is frequently exhibited in a de- 
cided crack along the cavity-margins, easily visible to the naked 
eye, and capable of allowing the ingress of deleterious agents cal- 
culated to bring about recurrence of decay around the filling. 
These cracks do not need to be large enough to be seen in order to 
invite mischief, and very many teeth have been lost in the past as 
the result of this one characteristic of amalgam. The color of 
amalgam is also against it, but particularly the fact that much of 
the amalgam used by the profession has so changed color after 
its insertion in the mouth as to render it most unsightly. ISTeither 
has the blackening process always been confined to the material 
itself, — the teeth, in many instances, being so badly stained by it 
as to remain discolored for life. 

These various faults of amalgam have claimed the attention of 
the profession for years, but no one would seem to have overcome 
them in any encouraging degree till the investigations of Dr. 
Black. After the most painstaking study of the physical character 



FILLING-MATEKIALS. 163 

of the various alloys, he was finally enabled to produce one which 
would neither shrink nor expand, and which would sustain suffi- 
cient stress to make it reasonably serviceable in the mouth. But 
the conditions surrounding the manufacture and manipulation of 
such an alloy are so intricate and so exacting, and the ingredients 
so sensitive to the slightest variation in temperature or in treat 
ment, that to produce a uniform product from one time to another 
would seem to be well-nigh beyond the possibility of human attain- 
ment. Manufacturers find that an ingot melted from a given 
formula may give a certain result, while another ingot from the 
same formula, and apparently treated in the same way, will show 
a variation in the result. The closest attention to the minutige is, 
therefore, necessary all along the line, from the refining of the 
original metals down to the filing and annealing of the finished 
product. Even then no one batch of alloy should ever be sent 
out short of a final test of the amalgam made from it by the most 
delicate machinery; and, in passing, it may be stated that when 
these tests are made they frequently prove a source of discourage- 
ment to the conscientious manufacturer. Discrepancies arise at 
every hand where, apparently, the greatest care had been taken 
with the preparation, and the more this amalgam question is 
studied, the more it Avould seem to be hedged about by limitations 
so great as to be disheartening in view of the immense amount of 
the material being used at the present day. It would probably 
be better for the' profession and the public if much of the energy 
which is now being expended on amalgam were diverted to other 
materials which are capable of more definite and uniform results. 
And yet amalgam under existing conditions cannot well be ex- 
cluded from our present list of filling-materials. It has been too 
useful for certain purposes, even with its limitations, to be entirely 
discarded. Its chief utility relates to the building up of teeth so 
badly broken down or so remotely situated in the mouth as to ren- 
der the use of gold too exacting, and also to the saving of teeth 
whose peridental membranes are so impaired as to preclude the use 
of the mallet. Employed with discriminating care, amalgam may, 
under these conditions, serve a useful purpose; but it can never 



164 PKINCIPLES AND PEACTICE OF FILLING TEETH. 

hope to attain to tlie same degree of excellence as a saver of teeth 
that has long since been established by gold. 

Tin. 

The statement has often been made that this material does not 
claim from the profession the attention which its virtues merit, 
and this is probably true, though it would seem that the combina- 
tion of gold and tin possesses all of the advantages of tin alone, 
together with the added virtue of being better able to resist wear 
on account of its greater hardness. 

Tin may be used in one of two forms, — that of foil, or in the 
form of shavings cut from block tin. The former is perfectly 
non-cohesive, while the latter, if freshly cut, is said to possess cohe- 
sive properties, though tin cannot be built into contours with any 
assurance of peinuanence on account of its softness. The indica- 
tions for the use of tin are practically the same as those suggested 
for gold and tin, — it being especially useful in any position where 
it is surrounded by four walls and is not subjected to wear. It is 
readily adapted to the cavity, will retain its form perfectly, except 
under pressure, and it is a poor conductor. This suggests that tin 
may serviceably be employed in simple cavities on all posterior 
teeth, such as buccal or lingual cavities of limited area, or in proxi- 
mal cavities which do not involve the occlusal surface. 

Cements. 

There are three main varieties of cement, — ^the oxychloride of 
zinc, the oxyphosphate of zinc, and the oxyphosphate of copper. 
The oxychloride of zinc is indicated in pulpless teeth, for filling the 
pulp-chamber after the canals have been previously filled with 
gutta-percha, and also to form a lining to the cavity under the fill- 
ing proper. It is seldom indicated in teeth with living pulps, par- 
ticularly if there is a near approach to the pulp or if there is much 
hypersensitiveness, on account of its strong irritating properties. 
IsTeither can it be relied on for reasonable service in any position 
where it is subjected to the fluids of the mouth, from the fact that 
it is so readily dissolved, — ^this being especially true of proximal 
cavities at the gingival margin. 



FILLING-MATERIALS. 165 

The oxypJwsphate of zinc is an excellent agent as an inter- 
mediate under metal fillings in cases where there is a near approach 
to the pulp, — it being less of an irritant than the oxychloride, — 
and also for a temporary filling-material in the management of 
teeth which for any reason may not be in a condition for a perma- 
nent operation. Its chief limitation consists in a tendency to dis- 
solve under the fluids of the mouth, though it is not so subject to 
this fault as is the oxychloride, and there is a considerable variation 
in its behavior in different mouths. In some instances it seems to 
wear well for years, particularly if the material used is of superior 
quality and it receives proper manipulation, but at best it may be 
accounted only a temporary expedient, and should not be relied on 
for permanent service. 

The oxyphosphate of copper, introduced by Dr. Ames, of Chi- 
cago, is also somewhat soluble in the mouth, particularly in vulner- 
able positions; and the fact that it is intensely black in color limits 
its use to positions not exposed to view. It is especially indicated 
in remote cavities on the necks of teeth occasioned by a recession 
of the gum, where the cavity is so ill defined as to make the use of 
gutta-percha or amalgam difficult. It may be made to adhere to 
the surface of a cavity very tenaciously, so that little undercutting 
is necessary, and it will prove an excellent expedient in that par- 
ticular class of cases for which no other kind of filling seems suited. 

Gutta-Percha. 

This is a material which deserves more attention from the pro- 
fession than it has received. In the particular field for which it is 
best suited it has no equal, and its uses are varied and unique in the 
saving of teeth. Its chief limitation lies in the fact that it is not 
sufficiently hard to withstand attrition, but placed in positions se- 
cure from wear it gives most excellent results. It is not dissolved 
by the fluids of the mouth, and it is one of the best of non-conduc- 
tors. As a temporary sealing agent in the treatment of teeth it is, 
without question, the best material we possess. It is especially in- 
dicated for the filling of pulp-canals, being non-irritant, impervious 
to moisture, and readily molded to fit any inequality in the canal. 



166 PRINCIPLES AND PRACTICE OF FILLING TEETH, 

It is also very valuable as a temporary filling-material in connec- 
tion with oxyphosphate of zinc for proximal cavities, tlie gntta- 
perclia being used in the gingival third of the cavity and the filling 
completed with cement. Gutta-percha will not dissolve out under 
these conditions, as will any of the cements; nor will the latter 
wear away so rapidly under attrition as will gutta-percha, so that 
by combining the two materials in this manner in the same cavity 
the operator gains the advantage of more adequate protection to 
the gingival margin and a better wearing service on the occlusal 
portion of the filling. 

Inlays. 

The discussion of filling-materials at the present time would 
hardly be complete without a careful consideration of inlays. The 
desirability of controlling caries in the anterior part of the mouth, 
without the necessity for -an objectionable display of gold would 
seem to be apparent, as also would the possibility of saving badly 
decayed teeth in any location where the insertion of gold foil is 
contraindicated on account of too great tax on the patient, or too 
much infiiction on an impaired peridental membrane by the mal- 
let. Crown-work, as the result of the considerations just indicated, 
has often been resorted to by operators in cases of extended decay 
at a period earlier than would make crowning justifiable if some 
more feasible means could be employed to tide the tooth over a 
number of years. It is in cases of this kind that inlay work finds 
its most legitimate field. 

While inlays have not been sufficiently long in general use to 
establish their precise status as to permanence, yet the recent ad- 
vances in their manufacture would seem to give hope for an ex- 
tended field of usefulness. One apparent limitation which for- 
merly deterred many operators from placing confidence in them 
would appear from observation to be less serious than was at first 
supposed. The fact that inlays must be held in place by cement — 
a material which had been proved to be more or less soluble in the 
mouth — led to the fear that there would be a failure along the 
margins of the inlay through solution of the cement, but it is 



FILLING-MATERIALS. 167 

found that the behavior of cement under inlays is different from 
that of the same material when used in fillings. It is true that 
there is a solution of the thin line of cement around an inlay for 
a slight depth, so that in a short time after the inlay has been set 
there is no cement in sight between the enamel and inlay on the 
immediate surface. But it will usually be found that the loss of 
cement extends only a trifling distance and there stops, lea^dng the 
cavity perfectly sealed for all practical purposes. Cement there- 
fore between the inlay and the cavity walls — aside from this mere 
surface loss — seems to be indefinitely stable, always provided of 
course that the inlay fits the cavity and that the cement is of a 
good quality and properly mixed. 

This does not imply that the cements we have to-day are perfect 
for the setting of inlays. Their opacity frequently interferes with 
the best effects in shading when employed under porcelain inlays, 
and accordingly the most suitable cement for this purpose would 
be one of a translucent character. As yet no such cement has 
been made available. 

Then, again, with our present cements it is found that inlays 
occasionally loosen even when care has been exercised in fitting 
them to the ca^•ity. This probably results either from the fact 
that the cement is not sufiiciently adhesive or because it shrinks 
slightly and does not perfectly seal the interstices between the in- 
lay and the cavity. In any case where there is the slightest likeli- 
hood of an inlay loosening, through limitations in the form of 
the cavity or from any other reason, the contingency should be 
explained to the patient at the time the inlay is inserted, so that 
there may be an intelligent conception of the conditions, and not 
too great a disappointment in case a resetting becomes necessary. 

The cases most suited to the reception of inlays are in cavities 
on exposed surfaces of the anterior teeth, and in large cavities in 
bicuspids and molars where filling operations would prove too ex- 
hausting. The former should be of porcelain, for esthetic reasons, 
while the latter should be of gold. Gold inlays are more easily 
made than porcelain, and in localities subject to the stress of mas- 
tication are much less liable to fracture. They should therefore 



168 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

invariably be used in any position not exposed to view, and it is 
in this particular class of inlay work that tbe most satisfactory and 
permanent results are to be obtained. 



CHAPTEK VI I. 

GOLD. 

Cohesive and Non-Cohesive Gold. 

All gold for filling teeth should be as pure as it can be made. 
The distinction between cohesive and non-cohesive gold does not 
so much relate to its purity as to the condition of its surface. If 
two layers of gold foil which is perfectly pure and perfectly clean 
upon its surface be brought into intimate contact at ordinary 
temperatures, they will cohere. In other words, they will weld 
cold. Two pieces of gold in this condition cannot be rubbed to- 
gether without sticking. This is an inherent quality of gold when 
pure and clean, and it is gold in this state which is termed cohesive 
gold. 

If pure gold foil be exposed to the atmosphere for any length of 
time, or is brought in contact with certain gases, it gathers upon its 
surface an imperceptible film, which, while not affecting the 
purity of the substance itself, interferes with its cohesion. Two 
layers of foil in this condition may be rubbed together without 
adhering. This is called non-cohesive gold. 

In accordance with this, it might naturally be assumed that, 
given a piece of pure and clean gold foil, it could be made cohe- 
sive or non-cohesive at will, and this is in strict agreement with 
fact. A pellet of cohesive gold may be made non-cohesive by ex- 
posing it to the infiuence of ammonia gas, and this pellet, thus 
rendered non-cohesive, may in turn be made cohesive by driving 
off the gas with heat. It is on this hypothesis that we anneal 
our gold for filling teeth. But there are some gases which, if al- 
lowed to come in contact with the surface of gold foil, apparently 
cannot be driven off by heat, and thus render the gold permanently 
non-cohesive. Exposure to the atmosphere under certain condi- 



GOLD. 169 

tions for an extended period seems to have the same effect, so that 
operators who wish their gold to work uniformly fresh and cohe- 
sive should keep it protected from the atmosphere. 

The difference in behavior of cohesive and non-cohesive gold 
under the plugger is readily suggested by the characteristics of the 
two materials. From the fact that mth non-cohesive gold one 
pellet may be forced across another without adhering to it we are 
able conveniently to carry such gold into corners of cavities diffi- 
cult of access and secure ready adaptation to walls, but the absence 
of cohesion between the layers of foil limits us in any attempt to 
build it into contours. With cohesive gold we have the advantage 
of giving any desired form to the filling and obtaining increased 
strength to the mass, with the limitation of greater difficulty in 
securing adaptation to points not easy of access. This does not 
imply that adequate adaptation cannot be gained with cohesive 
gold. Cohesive gold may be adapted to the wall of a cavity with 
as great a degree of perfection as can non-cohesive, but the method 
of manipulation is more exacting and less rapid. 

From the fact that a pellet of cohesive gold will immediately 
stick to gold which has already been placed in the cavity, care must 
be exercised in adding each fresh pellet to locate it in precisely 
the position where it is intended to condense it. If it is allowed to 
come in contact with any part of the surface remote from the point 
indicated, it cannot be forced across the surface to the proper posi- 
tion on account of its cohesion. With non-cohesive gold there is 
more latitude in this particular, but, properly placed and thor- 
oughly condensed, cohesive gold may be made to seal a cavity per- 
fectly. 

Annealing Gold. 

Much of the difficulty experienced by operators in the insertion 
of gold is due to faulty methods of annealing; and, even among 
operators who are sufficiently skilled to obtain good results by the 
ordinary methods, there is much to be gained by adopting some of 
the more recent advances in this important particular. The great 
majority of operators are in the habit of annealing their gold by 
passing it through the flame of a spirit lamp or a Bunsen burner, — 



170 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

a method whicli lias serious objections. In either instance we are 
never certain of always having a pure flame, and if we do not have 
a pure flame we jeopardize the working quality of the gold. An 
alcohol flame is seldom uniform in its character, from the fact that 
it is so appreciably affected by atmospheric changes. An undue 
humidity in the operating room will result in a vitiated flame, 
which shows itself in a yellowish tinge. The presence of moisture 
in the air always affects this flame, owing to the great affinity which 
alcohol has for water. 

The gas flame from a Bunsen burner is more reliable than the 
alcohol flame, but it is not without its limitations. The operator is 
always dependent on the gas company to furnish him a pure qual- 
ity of gas, and he must watch the burner to keep it in perfect work- 
ing order if he expects a uniform flame. Even at the best, it ia 
doiibtful if gold coming in contact with any flame is not in more 
or less danger of contamination. 

Then the manner of annealing followed by many operators is 
calculated to give unequal results, even with a pure flame. If a 
pellet of gold be picked up by the pliers and carried through the 
flame and then to the flUing, as is so frequently done, nearly one- 
half of the pellet is imperfectly annealed. The portion of gold 
grasped by the pliers is not annealed at all, and for some distance 
from the plier-points the gold is kept sufficiently cooled by the 
points to prevent perfect annealing. This accounts for much of 
the pitting on the surfaces of some gold flUings. A certain portion 
of every pellet is left non-cohesive, and when wear is brought upon 
the filling these little particles which were grasped by the plier- 
points flake off, leaving an imperfect surface. The operator does 
not notice this defect while building up the filling because of the 
fact that the end of the pellet most remote from the pliers is well 
annealed, and this, coming in contact with the gold in the cavity,, 
adheres perfectly, and the whole pellet seems to mallet down to 
place in good condition. It is only when subsequent attrition on 
the filling discloses the flaked surface that the operator realizes 
there is something wrong with the density of his gold; and even 
then he is quite likely to attribute it to some inherent defect in the. 



GOLD. 



171 



gold rather tlian to faulty methods on his part. This plan of 
annealing also occasionally leads to another detrimental effect. 
The operator, in obser^-ing the pellet in the flame, notes that it is 
dark in color for more than half its length from the plier-points, 
and attempts to get a uniform heating by holding it longer in the 
flame. This results in the overheating of the pellet at the end 
most remote from the pliers, and the fusing together of the layers 
of foil at that point so as to present a harsh, unyielding mass, with 
which it is impossible to do uniform work. If an operator must 
employ the flame for annealing he would better use the smallest 
pliers obtainable, and grasp the minute corner of one end of the 
pellet and pass it carefully through the flame, or near the flame, till 
the other end reddens. Then, dropping the pellet in the gold 
drawer, he should pick it up again at the annealed end and gently 
heat the other one. In this way both ends are annealed; but even 
then there is a lack of uniformity in such a method, and it also re- 
quires unnecessary time and undue manipulation of the pellet 
before it reaches the cavity. A pellet should be handled as little 
as need be from the time it leaves the gold-beater till it is placed in 
position in the tooth. 

Another method employed by some operators to obviate the 
difficulties just indicated is to roll their foil into a rope of suitable 
size, and then anneal the entire rope, cutting it into pellets subse- 
quently. An objection to this is found in the fact that with a rope 
of annealed gold the impact of the scissors in cutting the pellets 
compresses the rope so that there is a line of condensed gold across 
each end of each pellet before it is placed in the cavity. This may 
appear a trivial consideration, and yet it is attention to the minutise 
which goes to make up the most perfect result in the insertion of 
gold. A pellet condensed at either end in this way is not so 
obedient to the plugger, nor can it be so accurately manipulated in 
the performance of delicate work as can a uniform pellet. 

The plan of some operators whereby the plugger-point is used 
to pick the gold from the drawer and carry it to the flame and then 
to the cavity, is objectionalde in several particulars. Unless the 
point is heated sufficiently to ruin its quality as a plugger, the gold 



172 



PKINCIPLES AND PRACTICE OF FILLING TEETH. 



is never perfectly annealed in the region of the point. If it is 
annealed at all adequately, the point is made so hot as to be pain- 
ful to the patient on application to the tooth, and the products of 
repeated oxidation at the end of the point are continually being 
incorporated into the structure of the filling, which, at best, cannot 
result to its benefit. There is also a lack of uniformity in the 
degree of annealing throughout the pellet, the ends being invari- 
ably heated higher than the part touched by the plugger-point. 
The same condition exists, though in a modified degree, when a 
smaller instrument is used for picking up the gold in lieu of a 
plugger, as practiced by some operators. Another minor objec- 
tion relates to the fact that when a pellet is annealed in this way it 
has a tendency to slightly change its form under the fiame, so as to 
drop from the plugger or annealing instrument and fall into the 
flame. 

In view of these considerations, it would seem desirable for the 
profession to adopt a different method of annealing gold to obtain 
the best results. The problem to be solved is simply to heat the 

Fig. 84. 




gold sufficiently to effectively drive off all gases from its surface 
without the possibility of concurrent contamination, and with abso- 
lute uniformity of annealing throughout the mass. Yarioua 
methods have been devised for this purpose, the one most em- 
ployed in the past being to place the gold on a mica or metal 
tray over the spirit lamp, and allow the heat thus generated to 
gradually accomplish the purpose; but the most perfect method 



GOLD. 173 

yet suggested is throiigli tlie medium of the electric gold annealer 
devised by Dr. L. E. Custer, of Dayton, Ohio (Fig. 84). AVith this 
appliance complete uniformity of result is obtained in the most 
convenient and ready manner, and with no liability of contamina- 
tion. Even to operators who have been accomplishing apparently 
satisfactory results by other means, this appliance will soon reveal a 
working quality to the gold which seems impossible of attainment 
in any other way, and it is confidently believed that its general 
adoption by the profession would disarm much of the criticism 
which is occasionally waged against the manufacturers of gold on 
the plea of lack of uniformity in preparation. The only procedure 
necessary is to place the pellets in convenient arrangement on the 
annealer and turn on the current, which may be left running to the 
end of the operation. No matter how long the current is on, there 
is no overheating of the gold. It simply anneals perfectly, with- 
out ever fusing any of the layers of the pellets together. 

A most satisfactory manner of treating gold from the time it 
reaches our hands till it is carried to the tooth is to first subject it 
to the influence of ammonia gas by placing in a small porcelain 
receptacle a pledget of cotton saturated with aqua ammonia, and 
setting this in the same drawer with the gold, leaving the box or 
bottle containing the pellets open, so that the gas may readily act 
upon them. The pellets are thus rendered uniformly soft, velvety, 
and manageable. They are absolutely non-cohesive. They may 
be shaken or rubbed together ad libitum without one pellet, even 
in the slightest degree, adhering to another. When the filling is 
to be made they should be transferred to the annealer and the cur- 
rent turned on, the result of which mil furnish a series of pellets 
each in its behavior precisely like its fellow. Gold treated in this 
way has a beautifully soft working quality, devoid of harshness, 
but capable of perfect cohesion and density under the impact of the 
plugger. 

With gold prepared according to these details, and with the 
characteristics of its manipulation perfectly understood, it is nearly 
or quite as easy of introduction into a cavity as any of the other 
filling-materials, the chief distinction being the greater length of 



174 



PRINCIPLES AiS'D PllACTICE OF FILLING TEETH. 



time necessary to insert it. It must be built up piece by piece, 
while most of the other materials may be added in masses of 
greater bulk. 

Fig. 85. 




For those practitioners who are not convenient to the electric 
current, an annealer has been devised by Dr. J. B. Vernon which 
may be used with either gas or alcohol (Fig. 85). A convex disk 
is placed under the receiving tray and left open in the center in 
such a way that the flame passing through the aperture distributes 
the heat rapidly over the entire area of the tray. The degree of 



GOLD. 175 

heat may be regulated not only by the size of the flame, but by the 
adjustable nature of the frame, which admits of the tray being 
raised or lowered at will. This is a very simple and effective 
annealer and one that may be made available in any office. 

It would seem that either of these annealers was greatly to be 
preferred to the method so commonly in vogue of passing the gold 
through the flame, and a careful consideration of this entire sub- 
ject of the proper preparation of our gold for filling teeth is hereby 
strongly commended to the profession. Gold has almost invariably 
been credited with the advantage of having claimed a more serious 
study in its management and a greater care in its manipulation 
than any other filling-material we possess, and yet in this one par- 
ticular it would sometimes appear as if it had been strangely mis- 
understood in its characteristics or ignored in its chief require- 
ments. 

Different Forms of Gold. 

The form in which gold is used in filling teeth is largely one of 
individual preference, whether in ropes, pellets, cylinders, or strips. 
Possibly the best results are obtained by a convenient arrangement 
of the different forms in the same cavity, such, for instance, as 
starting the filling -with a rope of non-cohesive gold of suitable size 
and building the main body of the filling with pellets or cylinders 
annealed, followed by strips of heavy gold upon the surface. 
Some operators are in the habit of twisting their foil into ropes, and 
cutting these into pellets for general use. Others, whose methods 
of operating are highly individualized, cut the foil into strips and 
roll these into cylinders of varying sizes for the special case in 
hand. One advantage of this method is that the layers of foil con- 
stituting the cylinder are arranged in a regular series, one upon 
the other, and are therefore capable of a more even placement in 
the filling than when the pellets are cut from a twisted rope. 
This even arrangement of the layers of foil in building a filling is 
an item of some importance in its relation to the strength of the 
filling and its uniform density, but the element of time in the 
preparation of these cylinders must also be acknowledged as a 
consideration with the busy practitioner. The prepared pellets or 



176 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

cylinders of graded sizes and lengths, as thej come to us from the- 
manufacturers, would seem to furnish a most convenient form for 
the bulk of our work, and these, supplemented on the surface in 
cases calling for special density with strips cut from ISTos. 30, 60,. 
or 120 gold, are capable of producing a uniformly good result. 
For the rapid-acting mallet, in cases where it may not seem 
desirable to use the heavier foils, strips can be prepared by fold- 
ing the lighter foils and cutting them into suitable widths. For 
instance, a sheet of No. 4 foil may be folded three times, which 
makes four layers of foil. This fold is then cut into strips of from 
two to three millimeters in width, making a very convenient prepa- 
ration for the rapid mallet, tacking one end on the filling and fold- 
ing it back and forth across the surface as it is being condensed. 

For those operators who do not use the rapid mallet and who find 
the heavier golds inconvenient or difficult of manipulation for 
surface work, the following method of preparing the gold ia 
strongly advised. The folds just mentioned do not contain a suf- 
ficient number of layers of foil to build up with any rapidity under 
the slower mallets such as the hand mallet or the automatic, but the 
order of arrangement of the layers is good and should be preserved. 
To do this take a whole sheet of ISTo. 4 foil and fold it once, having 
the margins even and the one layer pressed flat on the other. Then 
fold again in precisely the same way, pressing flat and even, and 
continue the folding till the width of the resulting ribbon is about 
five or six millimeters, or a trifle less than a quarter of an inch. 
This flat ribbon may then be cut into strips from two to six milli- 
meters wide, according to the requirements of the case in hand. 
Gold prepared in this way will be found very effective in securing 
a uniformly dense and perfect wearing surface to fillings. The 
little pads after annealing should be laid upon the filling with their 
sides flat against the surface and in precisely the position where 
it is intended to condense them, and each pad should be thor- 
oughly condensed before another is added. If the final one-third 
of the filling be built up in this way there will be less complaint of 
faulty surfaces, both as regards wearing quality and appearance. 

The form of the different kinds of gold will receive more de- 



GOLD. 177 

tailed mention incidentally with the consideration of their intro- 
duction into the various classes of cavities. 

Crystal Golds. 

Crystal gold is prepared by precipitating the gold into crystals 
instead of by beating it into foil. Its working qualities are some- 
what different from foil, and its characteristics must be well under- 
stood in order to obtain good results. Some operators seem to 
have a peculiar, aptitude for manipulating this kind of gold, and 
are able to use it more satisfactorily than foil, but for the great 
majority of practitioners it can never be relied upon to do the same 
service as foil in the varying conditions presented in different 
classes of cavities. Its main virtue lies in its tendency to remain 
placed in the bottom of a cavity when once forced there. It does 
not so readily curl away from a wall, or rock under subsequent 
pressure, as does foil, and it is therefore indicated for starting the 
filling in those cases where the best retentive form to the cavity at 
this point has not seemed possible of attainment. It is also more 
rapidly condensed in a cavity, the filling apparently growing in 
bulk at a greater rate of speed under the plugger than where foil 
is used; but this very rapidity of growth may prove an element of 
insecurity in the constant danger of bridging over spaces and leav- 
ing a filling imperfect in density. This may readily occur with a 
careless operator, while the surface of the filling appears satisfac- 
tory. The fact that large masses of crystal gold may be inserted 
into a cavity and matted down to place with apparent ease is cal- 
culated to mislead many operators. These large masses behave 
much like wet snow under pressure, — they condense on the surface 
but are inclined to remain porous in the depth of the mass. In 
order to accomplish good results with crystal gold, and do justice 
to the material, the very greatest care must be used in its manipu- 
lation. It will not tolerate the range of usage that will foil, and 
unless an operator is prepared to give a careful study to its peculiar 
requirements he would better not employ it.. The chief distinction 
in this connection between foil and crystal gold is that foil demands 
care, and so expresses itself at every turn, while the other demands 

12 



178 PEINCIPLES AND PRACTICE OF PILLING TEETH. 

equal or greater care, but seems constantly to give the impression 
that it does not. 

As to the form of crystal gold best adapted for serviceable work, 
those preparations in which the deposit has been carried on long 
enough at one time to produce crystals or spiculse of considerable 
length would seem to offer the greatest promise of usefulness, both 
as to strength of the finished product and convenience of manipula- 
tion. A mat of gold formed of small crystals is granular in struc- 
ture. It is easily disintegrated in handling, and crumbles so as to 
waste extensively; while a filling made from it cannot be expected 
to present the same strength in a given mass that would one made 
from gold of a more fibrous nature. Another important considera- 
tion in this connection is that a fibrous gold may be expected to 
result in better margins to the filling than one of a granular struc- 
ture. One serious limitation to some of the crystal golds offered 
in the past has been the insecurity of the material when built over 
beveled enamel-margins, on account of the tendency to disintegrate 
and crumble away. The more perfectly the fibrous arrangement 
is maintained, the greater strength may be expected of the material. 
Recent improvements along this line in the manufacture of crystal 
golds would seem to promise an increased usefulness for them in 
practice, but, as already intimated, no operator should employ 
them without a perfect understanding of their peculiarities. 

The main points to be considered in manipulating crystal gold 
relate to accuracy in placing each pellet as it is carried to the 
cavity, to a careful selection of the cases suitable for its use, and 
to the proper form of plugger-points. Each piece of gold should 
be carried precisely to the spot where it is intended to condense it, 
and it should not be disturbed by too much manipulation before it 
is condensed. It is quite impossible, with crystal gold of good 
cohesive texture, to move a pellet of it across the surface of the 
gold already in the cavity for the purpose of securing a more con- 
venient position. Any attempt to insinuate it out of the location 
first taken will result in tearing the uncondensed pellet so that it 
is disintegrated and wasted. 

The places where crystal gold is indicated are in starting fillings 



MALLETS AND MALLETING. 179 

in difficult cases, and in large, open cavities easy of access, where 
the gold may be conveniently laid on in regular arrangement and 
condensed under the eye of the operator. It should not be em- 
ployed for filling undercuts or remote positions in cavities, on 
account of the tendency to bridge. 

The pluggers best adapted to its use are the oval-faced forms, 
with shallow serrations. For starting the filling a large point 
should be used, with vigorous hand-pressure, to carry the mass in 
front of the plugger instead of puncturing it; but as the filling is 
being built up too large points must not be used, for fear of failure 
in density. A convenient method of condensing the main portion 
of the filling and securing an even surface is to use a rapid mallet 
with the Royce plugger-points. These points, being oval on their 
serrated ends, may be swept back and forth across the surface 
of the filling with little danger of tearing the uncondensed gold 
away and wasting it, as is sometimes the result with flat-faced plug- 
gers. The Eoyce pluggers should be held a short distance from 
the condensed surface, so that the jump of the mallet catches the 
gold in front of the plugger and mats it to place. 



CHAPTER VIII. 

MALLETS AND MALLETING. 

The selection of a mallet for the insertion of gold is a matter 
which must be left largely to the individual preference of the 
operator, and yet there are distinguishing characteristics related to 
the different forms of mallet which call for consideration. Laying 
aside the factor of personal equation, we must not ignore some of 
the fundamental qualities inherent in the nature of the appliance 
which influence its practical utility. 

The Hand Mallet. 

This mallet was the first to be used for condensing gold, and it 
would seem to-day to be capable of a wider range of service than 
any other single form of mallet. No other mallet yet suggested 



180 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

has SO many advantages with so few disadvantages. Its chief limi- 
tation relates to the necessity of employing an assistant to manipu- 
late it, owing to the fact that the operator has too many uses for 
his left hand to make it convenient for him to employ it for this 
purpose. It is true that some practitioners prefer to do their own 
malleting, and by constant practice become very expert, but in the 
daily routine of gold filling there are too many demands on an 
operator's vitality without adding to them in this particular. 'No 
operator can do his own malleting without placing himself in a 
more strained position than would be necessary if some one else 
malleted, and there are times when it seems almost imperative to 
utilize both hands for other purposes. While it may be possible 
to strike a more intelligent blow and regulate the force more 
accurately to the requirements of the case, yet the method calls for 
too great a tax on the operator to make it desirable practice. 

The Assistant. — The problem of training an assistant to be a 
good malleter is a necessary concomitant to success in the use of the 
hand mallet. Usually a young lady assistant is best suited to this 
purpose, — one who has no intention of studying dentistry as a 
profession. The reason for this is that to be an expert malleter 
the assistant should have no interest in the operation except to use 
the mallet. A student of dentistry naturally becomes interested in 
the progress of the filling, and is inclined to divert the attention 
occasionally to the tooth instead of concentrating it solely upon the 
end of the plugger handle. This diversion results in imperfect 
work, and any imperfection on the part of the assistant renders 
the hand mallet almost the worst that can be used. The quickest 
perception is necessary to anticipate every move of the operator, 
and a young lady usually possesses this intuitive perception to a 
greater degree than the average young man. A nod of the opera- 
tor's head or the slightest intimation — so slight, in fact, that the 
patient need never be cognizant of it — is all that should be neces- 
sary to indicate to a capable assistant the character of blow re- 
quired, whether as to force or rapidity of stroke. The assistant 
should be trained to develop the wrist to the highest degree of 
suppleness, so that in striking the blow there shall be an entire 



MALLETS AND MALLETIXG. 181 

absence of arm-^veiglit exerted upon the mallet. She should also 
learn to use either hand with equal facility, but in the event of one 
hand being developed to a higher degree of perfection than the 
other, preference should be given to the left hand, on account of 
the fact that during most operations the assistant must stand on the 
left side of the patient, facing the operation, thus giving the left 
hand the widest range of usefulness. 

One of the most important considerations in the use of the hand 
mallet relates to the angle at which the mallet meets the plugger. 
The striking face of the mallet should be at direct right angles 
with the long axis of the plugger, or, in other words, the mallet 
should strike the plugger squarely on the end at every blow. Any 
deviation from this results in a glancing of the mallet across the 
end of the plugger, which interferes ^^ath its condensing power and 
proves very distressing to the patient. To invariably strike a 
square blow necessitates the constant attention of the assistant, 
added to a quick anticipation of any change in the angle made by 
the operator, so as to meet it with a corresponding change in the 
direction of the mallet blow. There should be developed between 
the operator and malleter the closest concert of action, and the 
one. should understand the methods of the other so perfectly that 
no verbal instruction is necessary during an operation. This har- 
mony of procedure is very reassuring to a patient and leads to confi- 
dence in both operator and assistant. 

The Kind of Mallet.— In 1S71 Dr. James Truman, of Philadel- 
phia, conducted a series of experiments with a view of determining 
the kind of mallet best suited to the condensation of gold, and 
more recently Dr. Clayton H. Stearns, of Owatonna, Minn., has 
thrown additional light on the subject in papers read before the 
Minnesota State Dental Society and the National Dental Asso- 
ciation. Though the methods of investigation of these two men 
were different in technique, their conclusions were in many re- 
spects similar so far as the essentials of their findings were con- 
cerned. 

The questions to be determined were the relative condensing 
power of mallets of different weights and of different materials, 



182 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

upon 'bases of varying degrees of hardness or softness as a medium 
of resistance to tlie mallet impact. Assuming tliat a tooth in the 
mouth is a partially non-resisting body, Dr. Truman's conclusions 
were summed up as follows : 

"1st. That hand pressure in the mouth can never condense as 
thoroughly as the mallet. 

"2d. That weight cannot entirely overcome mobility. 

"3d. That density and velocity are requisite in a mallet. 

"4th. That for hand malleting, the light steel mallet is to be 
preferred." 

It was found that hand pressure on a hard resisting base such 
as wood gave very nearly as good results as the light steel mallet 
on a similar base, but that the softer the base the greater the 
advantage in favor of the light mallet. It remains somewhat of 
a question as to the precise character of base the teeth present. 
In some instances they are undoubtedly to a large degree non- 
resisting, on account of impairment of the peridental membrane, 
but in other cases where they are firmly set in the jaws they are 
at least sufiiciently resisting to justify the judicious use of hand 
pressure in those positions where the mallet impact cannot con- 
veniently reach. 

Dr. Truman found in a rapid mallet such as the electric a com- 
bination of desirable qualities which made it almost the ideal 
instrument for condensing gold. It had density and velocity, 
which he laid down as requisites in a mallet, but in its application 
in the mouth the rapid mallet has its limitations, which will be 
considered later. 

Dr. Stearns also favors the light steel hand mallet, but varies 
somewhat from Dr. Truman in his recommendation as to what is 
most ser^dceable for practical work in the mouth. He advocates 
a heavy lead mallet — or lead covered with leather — ^for starting 
fillings with non-cohesive gold where large pieces of the material 
are used and the impact requires to be carried through the mass 
of gold to the wall of the cavity; this to be followed by a 2-oz. 
steel mallet for building the bulk of the filling, and finally the 
-2--0Z. hardened steel mallet to go over the surface. 



MALLETS AND MALLETING. 183 

The idea seems to be that the heavier the mallet and the softer 
the material of which it is made, the farther the impulse is carried 
bevond the immediate point of impact, while the lighter the mallet 
and the harder the material the more the energy is concentrated. 
For instance, if we strike a blow on a gold filling with a 6-oz. lead 
mallet the jar is felt thronghont the entire head of the patient, 
the impulse being carried on beyond the tooth, and the sensation 
in the tooth itself not being especially pronounced. But let us 
strike the same tooth as nearly as possible the same blow with a 
^-oz. hardened steel mallet and the energy seems concentrated 
right in the tooth with little jarring of the head. As one patient 
aptly put it, "That little hammer stings the tooth every time it 
hits." 

This question of the impression made on the patient by the 
various mallets becomes an important factor in the selection of a 
suitable one for the mouth, for however much we might wish to 
follow the mechanical philosophy of the mallet in our operations 
we must not ignore the sensibilities of the patient. 

With the principles of Drs. Truman and Stearns in mind, and 
Avith a very close study of the behavior of mallets in the mouth 
and the varying susceptibilities of patients in this regard, it would 
seem that in the majority of cases the best results were to be ob- 
tained in the following way : 

For starting fillings where the object is to adapt large masses 
of non-cohesive gold to the cavity walls, or where we wish to drive 
the first pieces of cohesive gold into the structure of the non- 
cohesive — in other words, where we wish the impulse carried 
through an appreciable mass — we should use a heavy lead or 
leather-covered mallet. For building the bulk of the filling, if the 
patient can tolerate it the 2-oz. steel mallet is probably more effec- 
tive in giving uniform density to the gold in the size of pellets we 
ordinarily use for this purpose than any other form of mallet. 
There is one feature of this mallet that recommends it highly for 
definite and precise work in building gold. AVith it the ex- 
perienced operator can tell instantly by the sensation conveyed 
through the plugger just when the gold is dense. He need not 



184 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

have one extra blow struck after density is readied — which can- 
not always be said when a soft mallet is used. 

But there are some patients who are so profoundly affected by 
the ring of a steel mallet that it is only common humanity to 
dispense with it and use the lead mallet for building the filling, 
even if in so doing we may sacrifice some of the hardness that would 
naturally be imparted by the steel mallet. For the surfaces of all 
fillings the -J-oz. steel mallet will be found to give a ringing hard- 
ness to the gold that cannot be approached by the use of any of 
the heavier or softer mallets, and after the first few stinging blpws 
the patient can usually tolerate this light mallet with little in- 
convenience. 

The prime objects to be attained in condensing a gold filling 
may be summarized as follows : 1st. To perfectly seal the cavity 
against leakage. 2d. To so compress the layers of foil throughout 
the filling that the mass will be free from air-spaces. 3d. To 
render the surface of the filling sufiiciently hard to withsitand the 
usage it is likely to receive in the mouth. 

The first of these calls for close adaptation of the gold to the 
cavity-walls, and this can best be obtained in most instances by the 
use of non-cohesive gold driven to place in appreciable masses. 
In every case where gold is being adapted to walls of cavities it is 
necessary to have a sufiicient layer of gold between the wall and 
the plugger to insure against injury to the wall by the point of 
the plugger. This is especially true in starting fillings, and for 
this purpose the driving force of the heavy soft mallet, carrying 
the impulse some distance in advance of the point of application, 
seems particularly well adapted. For welding the layers of gold 
together in the bulk of the filling the driving force is not so neces- 
sary — especially where the pellets of gold are laid on in regular 
arrangement as they should be — and the lighter, harder mallet is 
indicated. Theoretically the lightest steel mallet should do this 
work well, but there is one feature of the -J-oz. steel mallet which 
militates against its practical use in the mouth for the purpose of 
filling-building. The energy developed is at such high tension 
that the least over-malleting results in raising the molecular tension 



MALLETS AND MALLETING. 185 

of the gold to such an extent as to interfere with its cohesion. In 
other Tvords, if a light steel mallet is nsed on the surface of a filling 
and the malleting carried too far it mil be found impossible to 
make another piece of gold adhere to it. The gold in the filling 
would hare to be annealed again to make it cohesive. This does 
not imply that a good filling cannot be built with this mallet, but 
simply that in the hands of the average operator it will prove 
treacherous. 

This is one reason why the rapid mallet has not been more gen- 
erally used. Operators have found that occasionally the gold 
would fail to cohere with it, and it is only among the few who 
have mastered its peculiarities so as to know intuitively when to 
stop malleting that the instrument has been a success. A careful 
study of this matter will give a wider range of usefulness to the 
lighter mallets in building fillings. 

A statement of the third requisite in condensing gold, viz, the 
hardening of the surface, would imply that it is possible to render 
gold harder even after the layers are perfectly welded together, 
and this is true. A soft heavy mallet may bring the layers in 
close apposition to each other, but it can never make the surface 
so hard as the repeated impact of the light steel mallet. This can 
readily be demonstrated by any operator who tests it on his fillings. 

A thorough study of the principles involved in the use of the 
mallet in building gold fillings is strongly urged upon every den- 
tist, and to this end the conclusions of Drs. Stearns and Truman 
as summarized in the transactions of the I^ational Dental Associa- 
tion, 1901, will be found very valuable for reference. 

The Automatic Mallet. 

This mallet was devised to avoid the necessity of employing an 
assistant, and in the hands of some operators it seems to be an 
efficient appliance. But it may well be doubted whether it is ever 
capable of the same degree of delicacy that is easily attained with 
the hand mallet, or whether for most patients it can be compared 
to the hand mallet when comfort is considered. Given an expert 
assistant in a test of the two forms of mallets, and probably nine 



186 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

out of ten patients will select the kand mallet. There is a feature 
of the automatic mallet which doubtless may be held in some de- 
gree accountable for this aversion on the part of patients. In 
order to obtain the blow it is necessary to exert pressure on the 
filling with the plugger-point, and this pressure carried to a certain 
limit, causing a sudden recoil and blow, creates in the mind of the 
patient a series of anticipations which in the aggregate become 
exhausting. In other words, the patient is continually being 
warned by the pressure, that a blow is to be struck, and this re- 
peated leading up to the blow by pressure keeps the patient con- 
stantly on a tension. The precise character of the discomfort is 
not always capable of analysis by patients, and they are often 
unable to explain why they dislike the automatic mallet, but if 
this matter be carefully watched by the operator he will soon ascer- 
tain that there is invariably an intuitive flinching on the part of 
the patient whenever the pressure of the plugger is prolonged 
beyond the ordinary. It seems to be this interval of suspense 
which is trying to the patient more than the actual blow. All of 
this is avoided by the hand mallet. There is no advance pres- 
sure to herald the coming blow, and the character of the stroke 
is short, sharp, decisive, and instantly over. 

This recalls one feature of an automatic which would seem to 
have an important bearing on its utility. The stroke should be 
as short as possible consistent with volume of blow. Most auto- 
matic mallets have so long a stroke that their manipulation is a 
slow and awkward process, besides adding materially to the ele- 
ment of discomfort. An automatic, to do the best service capable 
of such an instrument, should work with a short, snappy blow, 
definite in quality and with a rapid rebound, so as never to miss a 
stroke. To attain this the appliance must be kept in the most 
perfect condition by repeated cleansing and oiling. 

The Rapid Mallets. 

Each of the various forms of rapid mallets has its adherents 
among operators, but probably the ones most in use to-day are the 
mechanical or pneumatic mallets operated by the engine or by a 



MALLETS AND MALLETIISTQ. 187 

motor. The electric mallet seems largely to have been displaced 
in recent years by others more readily kept under control and less 
complicated. It would seem that the ideal rapid mallet was one 
which, besides giving a definite blow at any desired speed, may be 
run by the motor. To operate a mallet with the foot engine be- 
comes wearisome in a long sitting. 

The only places suited for a rapid mallet are in cavities ready of 
access, where it is merely a matter of laying on the gold, and also 
for finishing the surfaces of fillings after the inaccessible parts of 
the cavity have been filled. It is hazardous to attempt to build 
gold around corners or to reach difficult positions with the rapid 
mallet. Such an effort usually results in bridging the gold over 
spaces, and fails in perfect protection of cavity-walls in the inacces- 
sible regions. 

It is often an agreeable change for the patient to have the rapid 
mallet substituted for the hand or automatic mallet as the filling 
nears completion. Any diversion in the character of the blow 
seems to afford relief from the monotony of a long sitting, and to 
be more acceptable to most patients than the continued use of any 
one kind of blow throughout the entire filling. For this purpose 
the rapid mallet becomes very useful, and it also materially 
shortens the operation. Gold may be condensed on an accessible 
surface almost as rapidly as the pellets can be carried to the tooth 
and placed by the assistant. This mallet also leaves a surface even 
and dense, if its manipulation be well understood. 

The proper method of using a rapid mallet is to sweep the 
plugger point across the surface of the filling from center to mar- 
gin, as if the gold were being wiped into the cavity. The process 
is entirely different from that of the hand or automatic mallet, and 
this fact should be recognized by those who attempt to use it. 
Care should be exercised not to over-mallet and destroy the cohe- 
sion of the gold, to which reference has already been made. 

As before intimated, oval-faced pluggers with shallow serrations 
are indicated for the rapid mallet, whereby the gold may be wiped 
down on the filling instead of being caught by the side of the 
plugger and torn off laterally, as would be likely to result with a 



188 PKINCIPLES AND PRACTICE OF FILLING TEETH. 

flat-faced plugger having a sharp angle between the serrated end 
and the shank. Another advantage of oval-faced pluggers relates 
to the safety of enamel-margins. The rapid mallet carrying a 
plugger with sharp angles is exceedingly prone to chop up or 
pulverize the margins unless the greatest care is exercised, but the 
oval-faced pluggers will permit greater freedom of action without 
injury. This watchful care of the enamel-margins is one of the 
necessary precautions in the use of any rapid mallet, and no opera- 
tor should attempt to use such an appliance without due apprecia- 
tion of its dangers in this respect. 

Hand Pressure. 

If an operator were rigidly confined to any one process for the 
insertion of gold, it is probable that he would do better service for 
his patient in the varying conditions presented in the mouth by 
the use of hand pressure than by any other one method, and yet 
the places where hand pressure is properly indicated are compara- 
tively limited. The great bulk of our work is better accomplished 
by mallet force, but in those occasional locations demanding hand 
pressure there seems to be nothing else which will at all adequately 
take its place. In distal cavities in molars and bicuspids there is 
often a certain region which cannot be reached by a direct blow 
of the mallet, and unless the operator recognizes this fact and re- 
sorts to hand pressure in building up the filling at these points he 
will fail of perfect protection to the cavity-walls. These inacces- 
sible locations are usually represented by the wall of the cavity 
which stands nearest to the operator, or, in other words, whose 
face is presented away from the operator so that it cannot be seen 
except with a mirror. 

For instance, in a disto-occlusal cavity on a right lower molar 
the buccal wall of the cavity can seldom be seen by the unaided 
eye, and the relation of the operator to this wall is such that direct 
mallet force against it is impossible. In a case like this the only 
certain means of securing adaptation of the gold to the wall is by 
the use of right-angle pluggers wielded by hand pressure. When 
these cavities are on the distal surfaces of teeth far back in the 



MALLETS AXD MALLETIXG. 189' 

mouth, or where the muscles of the lips are tense and unyielding, 
it is often necessary to build the entire gingival third — or even 
half — of the filling by hand pressure. 

The right-angle mallets devised as a substitute in the various 
cases indicated are useful in the hands of some operators under 
certain conditions, but it would seem impossible to get so accurate 
a placing of the gold by their use as by hand pressure. The gold 
can be "pulled" against inaccessible places or insinuated under 
overhanging walls where such conditions are encountered with 
greater precision by hand pressure than by any mallet force. The 
pluggers used for the purpose should have a very stiff shank with 
a large handle, capable of being conveniently grasped in the palm 
by which means most of the pulling force is best exerted. In order 
to be assured of perfect adaptation and an adequate degree of 
density with hand pressure, it is necessary to exert considerable 
force, and the plugger should be strong and the wall sufficiently 
thick to safely sustain this force. This recalls a certain mistaken 
idea which appears to be prevalent among operators as to the 
indications for and against hand pressure. The impression would 
seem to prevail that hand pressure is indicated when building along 
frail walls or over friable enamel. The exact contrary is the 
fact. No operator can with hand pressure secure the same de- 
gree of density or adaptation along weak walls that can safely be 
obtained by delicate blows of the mallet. This is particularly true 
of the hand mallet wielded by a trained assistant. 

One place where hand pressure is useful relates to the starting 
of all fillings. This can be readily accomplished on the wedging 
principle with non-cohesive gold, and the first pieces of cohesive 
gold may also often be carried to place and fastened into the sub- 
stance of the non-cohesive to good advantage with hand pressure. 
For this purpose a certain manner of manipulating the plugger 
should be observed, in order to obtain the most perfect results. 
It is seldom that a straight pushing or pulling force will prove as 
effective as will the same degree of force exerted with a wrist move- 
ment whereby the point of the plugger is held on the gold and the 
end of the handle is swayed back and forth so as to describe the 



190 PKINCIPLES AND PKACTICE OF FILLHSTG TEETH. 

short arc of a circle. If a right-angle plugger is being used, the 
swaying should occur at the angle. This insinuating spreading 
force accomplishes two objects: it carries the gold into every in- 
equality in the wall of the cavity, securing perfect adaptation, and 
the swaying motion also presses the uncondensed portion of the 
pellet which has curled up around the shank away from the plug- 
ger, allowing the instrument to be withdrawn without carrying 
the pellet with it. 

This same method of manipulation is very effective when for 
any reason not apparent to the operator a pellet of gold fails to 
adhere to the surface of the filling under mallet force. A rebel- 
lious pellet may be fastened to the filling by hand pressure exerted 
as just indicated, and made to remain more securely than by mallet 
force. The rocking motion of the plugger insinuates the substance 
of the loose pellet into the structure of the condensed gold and pina 
it to place to better advantage than if the mere property of sur- 
face cohesion were the sole dependence. For this purpose a plug- 
ger point with clean-cut, sharp serrations is indicated, and after 
several pieces have been added to the filling in this way it should 
be followed by the mallet over the surface to insure uniformity of 
density. 

It may be here stated that a more satisfactory wearing surface 
can be given to any filling with mallet force than is possible with 
hand pressure, though hand pressure fillings properly inserted 
usually succeed in saving the teeth. They do so by reason of good 
adaptation to the cavity-walls, thus preventing leakage, even in 
many cases where the wearing surface of the filling becomes pitted 
and unsatisfactory. IsTo filling which is subjected to the attrition 
of mastication should be considered safe, so far as the condition of 
its surface is concerned, unless the mallet has been employed in 
finishing the filling to impart a resisting property to the gold. 

Protection to the Peridental Membrane in Malleting. 

The problem of securing sufficient density to a gold filling so 
that it may safely withstand the usage to which it is subjected in 
the mouth without causing too much punishment to the peridental 



MALLETS AA'D MALLETING. 191 

membrane during the operation, is one which confronts the prac- 
titioner on approaching any cavity of considerable size. The peri- 
dental membrane is more or less elastic, and when a blow is struck 
on the tooth with a mallet the tooth is forced slightly into the 
alveolus, causing a compression of the membrane. Instantly fol- 
lowing this impact the membrane reasserts itself, forcing the tooth 
out again to its original position. Another blow drives it against 
the membrane once more, and the membrane again reacts. This 
repeated forcing in and out of the tooth soon results in such im- 
pairment of the membrane that if the process is kept up sufficiently 
long without protection the operator is finally pounding the tooth 
on a jellied membrane. 

This stage of injury is reached much sooner in those cases where 
the teeth have recently been wedged apart and are correspondingly 
loose, and this one factor becomes an important consideration in 
the choice of methods for gaining space as between previous wedg- 
ing and the use of a separator. Wherever sufficient space can be 
safely gained with a separator it will ordinarily result in less aggre- 
gate discomfort to the patient than will the process of previous 
wedging followed by an operation while the tooth is still loose. 
One important office of the separator is to hold the tooth firm 
against movement under the impact of the mallet, and it may often 
be profitably employed during an operation for this purpose alone 
in cases where space has previously been gained by wedging. In 
those instances where it has been necessary to wedge extensively, 
thus causing so great a movement of the teeth that they are left 
loose and sore, the operation of filling should invariably be de- 
ferred till the soreness subsides. The teeth may be held apart dur- 
ing this interval with gutta-percha. 

The whole problem of protecting the membrane against injury 
from mallet force relates to giving the tooth such support that it 
is held firm and immovable under the blow. This may be ac- 
complished in various ways, each case suggesting the method 
most suited to itself. Somei;imes a wooden wedge may be used for 
this purpose, or a separator as already indicated, but for an ex- 
tended operation the surest means is to hold an instrument in the 



192 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

left hand braced firmly against tlie tooth or filling throughout the 
operation. This kind of support is especially indicated as the fill- 
ing nears completion on account of the tendency to soreness at that 
time, and also because the surface of the filling requires the most 
thorough malleting to be assured of adequate density. If a tooth 
be protected in this way the membrane will ordinarily not rebel 
against mallet force sufiicient to condense gold into a serviceable 
filling, except in those cases where the membrane is impaired 
or is hypersensitive. When a tooth is loose from absorption of 
the alveolar process or from inflammation of the soft parts sur- 
rounding it, a gold filling of any size should not be attempted in it 
till the tooth is made firm by treatment. If it cannot be made firm 
the operator would better select some other filling-material. 

In some instances the peridental membrane is so weakened 
through lack of use that it is painfully responsive to mallet force. 
This is ordinarily brought about by the fact that when caries 
occurs the tooth becomes sensitive to mastication, and the patient 
involuntarily avoids its use to the end that the membrane, lacking 
its normal functional exercise, deteriorates in its resistive qualities 
so as to quickly rebel against the mallet. The remedy for this 
condition lies in subjecting the tooth to masticatory usage in ad- 
vance of the operation, by placing in the cavity a gutta-percha plug 
to control the sensitiveness and instructing the patient to bring the 
tooth into active service. In this way the membrane may be so 
toughened in a week or ten days as to receive the impact of the 
mallet comfortably. 

Another consideration connected with the toleration of the meni> 
brane to mallet force relates to the direction in which the pressure 
is brought to bear upon the tooth. If the condensation of the 
gold takes place in line with the length of the root, it will be found 
that there is less soreness than where an equal force is exerted, 
against the tooth laterally. With this idea in mind, all fillings 
requiring extended malleting should be so built, if possible, that 
the pellets of gold are laid at right angles to the long axis of the 
tooth and the plugger held parallel with this axis. When a blow 
is struck in this direction the force is distributed throughout the 



INTRODUCTION AKD FINISHING OF GOLD FILLINGS. 193 

entire surface of the membrane instead of being exerted against 
only one side of tlie root, as would result if a blow were struck at 
right angles to any of the axial surfaces. There are, of course, 
instances where lateral force must be employed, but these are 
usually in filKngs of limited area where the aggregate mallet force 
is not sufficient to leave any serious impress upon the membrane. 



CHAPTER IX. 



THE INTKODUCTIOISr, CONDEXSATION, AND TINISHING OF GOLD 
FILLINGS IN THE DIFFERENT CLASSES OF CAVITIES. 

"While each cavity is to a certain degree a law unto itself so fan 
as the manner of building the filling is concerned, yet there are 
fundamental principles of procedure which if intelligently recog- 
nized will render the work more systematic and satisfactory. The 
methods herein suggested are not always applicable because of the 
constant occurrence of cavities unique in location and form, but 
for the so-called typical cavities of the different classes it is believed 
that if intelligently followed they will at least prove effective in the 
accomplishment of satisfactory work. 

The arrangement in the cavity of the layers of foil constituting 
a pellet becomes a matter of some importance in its relation to 
the symmetrical growth of the filling under the plugger, and also 
to its resultant strength. It is with this idea in mind that the 
present plans of procedure have been suggested, as well as on the 
basis of expediency in the manner of building the filling. 

To start any filling a rope of non-cohesive gold, varying in size 
as indicated by the requirements of the case, will be found effective. 
A convenient form may be made as follows: Divide a sheet of 
1^0. 4 foil once, making one-half of a sheet; then roll into a rope 
about the size of a large knitting needle, and cut the rope in three 
parts. This makes a rope approximately an inch in length, and 
of a size that can be readily carried into most cavities of any 
extent. In small cavities the rope may be cut short enough for 
convenience, while in cavities of very large area it will be found 

13 



194 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

desirable to roll tlie rope from an entire sheet of foil and cut to 
suitable lengths. 

When starting a filling the rope should be grasped by the pliers 
about one-fourth of an inch from the end, and this end carried into 
the angle of the cavity where it is intended to commence the filling. 
The rope will fold upon itself as it is pressed into the angle, so that 
it will remain there while the pliers release it and grasp it farther 
back and fold it once more into the cavity. This process is kept up 
till the entire rope is carried into position, where it may be con- 
densed in the manner to be described when considering the details 
of filling-building in the different cavities. Into the structure of 
this non-cohesive cushion may be wedged the first pellets of co- 
hesive gold till the two forms of gold are so interlocked that they 
will not separate, when the filling may be completed with cohesive 
gold. 

Simple Proximal Fillings in Incisors. 

These fillings, when built from the labial aspect, are ordinarily 
best started in the gingivo-linguo-axial angle of the cavity by carry- 
ing a rope of non-cohesive gold into this angle as already indicated. 
The rope should be folded upon itself from the starting point along 
the gingival wall toward the labial wall, till it is securely locked 
between the gingival third of the labial and lingual walls. If the 
gingival wall has been made flat there will be little difficulty in 
securing the rope in place. The first rope used should be of suffi- 
cient size to cover the entire gingival wall from lingual to labial, 
and extend well over the gingival enamel-margin. The office of 
this rope is to secure ready adaptation to the angles of the cavity, 
and also to form a non-cohesive cushion against which cohesive 
gold may be condensed without danger of injury to the gingival 
enamel-margin. In condensing gold over margins it should 
always be a cardinal principle to keep a sufficient mat of gold be- 
tween the plugger point and the margin to avoid the possibility of 
injuring the enamel with the serrations of the plugger. 

When the non-cohesive rope has been carried to place with the 
pliers it should be more securely locked in position by bringing a 



INTRODUCTION AND FINISHING OF GOLD FILLINGS. 195 

plugger to bear on it at two or three points witli hand pressure, 
"wielded in the rocking motion already described. The first direc- 
tion of the plugger should be toward the gingivo-linguo-axial 
angle, and the gold should be wedged into this angle with con- 
siderable force. If the rocking motion of the plugger is used the 
gold can be so locked into place as not to be readily moved by 
subsequent manipulation, but if there seems any doubt about its 
security a retaining instrument may be placed on the condensed 
gold the moment the plugger is withdrawn, and held there while 
the locking process is carried on by the plugger at other points. 
The next direction of the plugger should be toward the gingivo- 
labio-axial angle, and these two points may be all that is necessary 
to condense at this time. The object is simply to lock the rope into 
the angles of the cavity rather than to attempt the condensation 
of the entire mass. In fact, too much condensation must be 
avoided until some cohesive gold has been called into service. 
After the plugger is withdrawn from the gingivo-labial angle a 
cohesive cylinder sufficiently large to cover the entire gingivo- 
lingual region should be laid with its side upon the non-cohesive 
gold and one end looking along the lingual wall and the other 
along the gingival wall. This should then be forced into the 
substance of the non-cohesive gold in the direction of the gingivo- 
linguo-axial angle, so as to incorporate the two forms of gold into 
one mass. After pinning this pellet of cohesive gold into the non- 
cohesive at several points with hand pressure, another cylinder 
of cohesive gold may be forced into the gingivo-labio-axial angle 
in the same manner. These two pellets will usually reach across 
the entire gingival wall, but if they do not a third one may be 
used to connect the two. When there is a complete covering of 
cohesive gold over the non-cohesive the mallet may be used for 
the first time, and the entire mass malleted to place. The result 
is that the gingival wall is perfectly protected by a cushion of non- 
cohesive gold covered by a layer of cohesive gold, and the whole 
locked between the labial and lingual walls of the cavity with a 
slight excess of gold overlying the gingival enamel-margin to in- 
sure sufficient material for a perfect finish. 



196 PRINCIPLES AND PEACTICE OF FILLING TEETH. 

In building the filling from this point the pellets of cohesive gold 
should be laid with their sides looking toward the gingival wall 
and their ends looking labially and lingually, and each pellet 
should be wide enough to reach from the axial wall to the extreme 
proximal surface of the filling. With this arrangement of the 
pellets the condensation is in the direction of the long axis of the 
tooth, and the filling is kept sufficiently prominent on its proximal 
surface while it is being built down to avoid the necessity of subse- 
quently adding any gold laterally to this surface to round out the 
filling. Gold tacked on the proximal surface of one of these 
fillings by laying the pellet on its side and directing the mallet 
force at right angles with the long axis of the tooth is not so se- 
curely maintained in place as it is where the arrangement of the 
gold is such that each pellet reaches from the proximal surface to 
the axial wall and is built toward the gingival wall. The operator 
cannot always avoid the necessity of arranging his gold so that 
the condensation is in the direction of the axial wall, but this neces- 
sity is usually confined to small fillings where the means of ap- 
proach will not permit of any other arrangement, and where the 
element of strength is not so material. 

One important consideration in building these fillings relates 
to the protection of the lingual margin. This seems to be the 
most difficult feature in their insertion, and it is where operators 
fail more often than at any other point. This failure is usually 
due to inadequate covering of the margin as the gold is being built 
along the lingual wall toward the incisal angle. A slight excess 
of gold should invariably be carried over this margin, and in order 
to be assured of this the operator should keep the gold in the 
lingual region built somewhat in advance of the filling at the 
labial margin. That is, the gold should extend farther incisally 
along the lingual than along the labial wall, so that the operator 
may clearly see the lingual margin and thus be certain of lapping 
the gold over it. If the labial part of the filling be built in the 
least advance of the other, it obstructs the view of the lingual 
margin and prevents access with the plugger. 

As the filling is being built down toward the incisal angle, the 



INTRODUCTION AND FINISHI^TG OF GOLD FILLINGS. 197 

operator must have a care not to approach too near the angle before 
wedging some gold into the angle and between it and the filling 
already in place. If the cavity is deep piilpally, so as to leave an 
appreciable pocket between the condensed gold and the incisal 
angle of the cavity, it is advisable to use a short rope of non- 
cohesive gold to wedge into this pocket to be assured of perfect 
adaptation. Into this non-cohesive gold a small pellet of cohesive 
gold may be forced with hand pressure, and the filling completed 
with the mallet. 

When a filling is thus inserted it will be found that there is a 
slight excess of gold overlapping the margins of the cavity, and the 
final step in condensing such a filling should be to mallet down 
this gold with a foot plugger. If access cannot be gained with a 
plugger a very thin burnisher may be used to force the gold to 
place, burnishing from the center of the filling toward and over 
the margins. Then the filling is ready for polishing. 

In ca^dties where the lingual wall is missing and the labial wall 
perfect, so that the filling must be built from the lingual aspect, 
the same general principles of filling-building may be followed, 
except that the gold should be started in the gingivo-labial region 
instead of the gingivo-lingual, and the filling kept more prominent 
along the labial wall as it approaches the incisal angle. The same 
care must be exercised in lapping an excess of gold over the labial 
margin while the filling is being built that was advised for the 
lingual margin while building from the labial aspect. It is well- 
nigh impossible to tack gold on the labial region of the filling after 
it has been built down to the incisal angle, and the operator should 
therefore provide perfect protection to this wall while he has the 
opportunity. 

In those cases with the lingual wall missing but the labial aspect 
po open that the filling must be built mostly from this direction, 
the gold should be started in the regular way, and as the lingual 
margin is being covered a portion of each pellet should be allowed 
to extend some distance over the margin and hang beyond the 
lingual surface of the tooth. This end of the pellet cannot be con- 
densed from the labial aspect, but the portion reaching into the 



198 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

cavity can be made fast to the filling and the filling built as full 
as convenient from this aspect. "When the labio-proximal portion 
of the filling is built to form it will be found that from the lingual 
aspect a large mass of uncondensed gold extends linguallj beyond 
the margin, each pellet of which is securely fastened into the 
substance of the condensed portion of the filling. This uncon- 
densed mass will ordinarily not contain sufiicient gold to properly 
round out the filling when malleted to place without the addition 
of more gold, and it is the addition of this gold from the lingual 
aspect which often proves troublesome to operators. To avoid 
difiiculty of this nature it is suggested to take an annealed pellet 
and force it with hand pressure up into the structure of the uncon- 
densed gold before malleting the latter to place. If this be done 
the freshly annealed pellet will leave a surface to which, if neces- 
sary, more gold may be attached with greater certainty than 
where the uncondensed gold has been malleted without this pre- 
caution. 

The object of leaving this excess of uncondensed gold is to 
enable the operator to interweave the freshly annealed pellets into 
its substance, and thus prevent flaking of the lingual portion of 
the filling, which is likely to occur where an attempt is made to 
condense the gold as the filling is being built down, and then add 
more gold to the condensed surface from the lingual aspect. 
Wherever possible the practice should be avoided of leaving for 
any length of time a condensed surface of gold exposed to the 
atmosphere with the expectation of subsequently adding more gold 
to it. The property of cohesion seems to be more or less impaired 
by exposure, and in order to secure the best working quality to 
cohesive gold it will be found desirable to add pellet after pellet to 
the freshly condensed surfaces from beginning to completion of 
the operation. 

Pluggers. 

The choice of pluggers becomes largely a matter of personal 
selection with most operators, but for these proximal fillings in 
anterior teeth the forms here illustrated would seem to answer a 
convenient purpose. Fig. 86 is suggested for starting the filling 



INTKODtrCTION AND FINISHING OF GOLD FILLINGS. 



199 



and locking tlie gold into the gingival third of the cavity. ltd 
length from the serrated end to the angle is sufficient to reach 
perfectly to the gingival region of any cavity on an incisor, and the 
degree of curve is such that direct hand pressure or mallet force 
may be exerted against the gingival wall. In cavities of large 
area with ready access much of the filling may be built with it to 
the point where the incisal angle requires protection, but for 
small cavities other forms are mostly indicated. 

As the incisal angle is reached a plugger of smaller size, and 
with a greater curve, is required, such as the pair, right and left, 
illustrated in Fig. 87. Occasionally even these forms will not 
properly reach the angle on account of the position of the proxi- 
mating tooth, and where such is the case a small, short right-angle 
plugger is indicated. Fig. 88. These right-angle pluggers are 
invariably to be used Avith hand pressure, and in cases difficult of 
access the gold may often be "tucked up" into an angle in this way 
when mallet force is entirely impracticable. 



Fig. 
86. 

■■■ 



Fig. 

87. 



Fig. 



Fig. 
90. 



Fig. 
91. 



For building fillings from the lingual aspect in all cavities of 
sufficient size Fig. 86 is especially adapted, on account of its 
adequate reach. In cavities too limited for its use, whether of 
labial or lingual aspect, the form illustrated in Fig. 89 may be sub- 
stituted to advantage in conjunction with the curved pair Fig. 87. 

One important factor in securing the most stable anchorage of 



200 PEINCIPLES AND PRACTICE OF FILLING TEETH. 

these fillings relates to perfect density of the gold along the angles 
which join the walls of the cavity. As has previously been stated, 
accurate adaptation of gold may be obtained to any angle provided 
the proper form of plugger point is used, and for this purpose such 
a form as that in Fig. 90 is excellent in those positions where it 
will approach. Another form suggested for places where Fig. 90 
will not reach, and especially for curving under the labial wall and 
carrying the gold into the angle between the labial and axial walls, 
is shown in Fig. 91. In cavities where these forms are not avail- 
able for the angles the curved pluggers with round points may be 
made to do good service, and secure perfect adaptation by exercis- 
ing care and malleting step by step along the angle so that the 
plugger point covers the entire mass of gold with the mallet im- 
pact. For the surface of these fillings, according to their area, 
pluggers ranging from Fig. 90 up to a small-sized foot plugger 
may be used to give an even, dense surface. 

Finishing Proximal Fillings in Incisors. 

When the filling is built to proper form the gold will ordinarily 
be found to knuckle tightly against the contact point of the proxi- 
mating tooth, and in finishing the filling the operator must avoid 
cutting away the gold at this point, and thus producing a flat 
proximal surface to the filling. The gold should be left rounded 
out to a contact point, the same as was on the tooth originally 
before decay began. To this end a narrow finishing strip should 
be used in the interproximal space to dress the gingival third of the 
filling to form, and this part of the filling should be finished even 
with the surface of the tooth before any attempt is made to trim 
the filling at other points. The strip should not be so wide that in 
drawing it back and forth between the teeth it will reach to the 
contact point and cut it down. If the filling is so snug against the 
proximating tooth that the strip cannot be carried between the 
teeth, it may be introduced endwise into, the interproximal space 
from the labial aspect. 

When the gingival margin is properly trimmed to form, the 
gingivo-lingual portion of the filling may often be dressed down by 



INTRODUCTION AND FINISHING OF GOLD FILLINGS. 201 

carrying the cutting surface of the strip — which is still in the inter- 
proximal space — as nearly as possible along the lingual surface of 
the tooth, and the back or smooth side of the strip across the labial 
surface of the proximating tooth. This brings pressure of the 
cutting side of the strip to bear immediately on the gingivo-lingual 
part of the filling, and it does not cut at any other point. 

After the narrow strip has been used it will often be found con- 
venient to slip on a separator where one has not previously been 
employed, and force the teeth slightly apart to admit of a finishing 
strip being carried between the teeth. Where this cannot be done 
a very thin, broad burnisher, battered out to a uniform thickness 
and having a sharp edge, after the nature of the Dunn hand matrix, 
should be forced between the filling and the proximating tooth, 
and the end of the handle swung back and forth, describing the 
arc of a circle, while the blade is held between the teeth till there is 
more or less freedom of movement of the burnisher. This will 
ordinarily smooth the gold so that a strip may be passed between 
the teeth. 

The strip used for finishing this portion of the filling should be 
broad, and in manipulating it the cutting surface should be drawn 
quite sharply across the labial and lingual surfaces of the tooth, so 
that the filling will be rounded and the labial and lingual aspects 
dressed even with the cavity-margins. In those cases where the 
lingual surface of the tooth is so concave that the strips will not 
follow the outline of the cavity, a sand-paper disk in the engine 
may be used to dress this portion of the filling to form by directing 
the disk into the concavity with a round-headed burnisher. 

After the filling is of the proper form it may be polished with a 
finishing strip of the finest grit, or thin linen tape may be used, 
carrying with it fine pumice, followed by whiting. All of this 
should be done before the removal of the rubber dam, on account 
of the protection afforded by the dam to the gums and lips, and 
also because the saliva interferes with the work. 

Whenever strips or disks are used in finishing gold fillings they 
should invariably be smeared with vaseline, oil, or some similar 
lubricant to avoid as much as may be the generation of heat in the 



202 PKINCIPLES AND PRACTICE OF FILLING TEETH. 

filling. The lubricant also renders the disk pliable, and it can 
therefore be directed into depressions with a round-headed instru- 
ment — snch as a ball burnisher — to much better advantage than 
where such an attempt is made with a dry disk. This practice will 
also prove of considerable financial advantage to the dentist if he 
will preserve his worn-out disks and strips and send them to the 
refiner. The amount of gold retained on the sanded surface, if 
lubricated this way, will in the aggregate yield a surprising profit 
in the course of a year, and no operator should ignore this kind of 
economy. 

Another aid in the maintenance of a normal temperature in a 
filling under the friction of a strip or disk may be made available 
by those who have compressed air at their command. If a jet of 
air be allowed to play upon the filling during the process of polish- 
ing, it will be found to equalize the temperature and render the 
work more tolerable to the patient. 

Proximal Fillings in Anterior Teeth involving the Incisal Angle. 

The method of building these fillings is practically the same as 
that for simple proximal fillings down to the point where the 
incisal anchorage is made, except that in the contour fillings the 
open aspect of the cavity renders it possible to more uniformly lay 
the gold on parallel with the gingival wall and at right angles to 
the stress of mastication., In these large fillings the proximal sur- 
face should be kept sufiiciently prominent as the filling is being 
built from the gingival to the incisal region, to make it unnecessary 
to add more gold laterally to the proximal surface to complete 
its contour. 

In those cases where the incisal anchorage has been made be- 
tween the two plates of enamel in the incisal third of the axial wall, 
the greatest care must be exercised in securing perfect adaptation 
and density of the gold in this anchorage. Small pieces of gold 
must be used, and each piece compactly malleted to place with 
small pluggers. The slightest lack of density or the slightest 
bridging of the gold at this point must eventually result in a spring- 



INTRODUCTION" AND FINISHING OF GOLD FILLINGS. 203 

ing away of the incisal portion of the filling which sooner or later 
leads to its loss. 

Where the incisal anchorage is made by cutting a step or groove 
across the end of the tooth at right angles to the proximal cavity, 
as suggested in considering cavity preparation, the method of build- 
ing the filling is to carry the gold down the proximal portion of 
the cavity level with the base of the step in the ordinary way, and 
then lay a pellet with its side presented to the floor of the step and 
its ends looking mesially and distally, reaching from the center of 
the gold already condensed over into the step. The pellet should 
be fastened securely to the condensed gold, and then malleted to 
place in the step. Another pellet should be laid slightly farther 
along the step, but with one end still lapping the gold already in 
place. In this way the proximal portion of the filling is securely 
locked into the step, and the greatest possible strength is given the 
gold at the point where the proximal joins the incisal portion of 
the filling by such an arrangement of the pellets. This process of 
building the gold should be carried on till the end of the step ia 
reached. The entire incisal portion of the filling must be built up 
with the greatest care, and the arrangement of the pellets, so far as 
possible, should be in the order already suggested, — the sides at 
right angles to the force of occlusion, and the ends looking mesially 
and distally across the step. 

The gold should be perfectly annealed and small pellets em- 
ployed, to the end that the greatest degree of density and resisting 
power is imparted to the gold. For this portion of the filling it is 
sometimes desirable to use the heavier golds in strips, such as the 
ISTo. 60; or in cases where extreme density is desired platinum 
and gold may be employed. If the heavy gold is used it should 
not be added till the surface is nearly reached, on account of the 
greater difiiculty of securing perfect adaptation to the labial plate 
of enamel. 

This is one of the most important considerations in building these 
fillings. Unless the gold is adapted to the labial plate with the 
greatest accuracy there will eventually occur a leak at this point, 
which will result in such discoloration as to make the tooth un- 



204: PRINCIPLES AND PRACTICE OF FILLING TEETH, 

sightly. The angle between the labial plate and the step should 
also receive close attention in adapting the gold, so that the filling 
may be securely seated in place. 

Tor building this portion of the filling pluggers 90 and 91 are 
admirably adapted, though larger sizes may be used in cases where 
the area of the cavity will permit it. In teeth long and thin, where 
the step must be correspondingly deep and narrow and where it 
has been made to terminate in a depression, for the more secure 
anchorage of the filling a plugger as small as Fig. 89 may be 
required to reach the deepest part of the step and bring this por- 
tion of the filling level with the rest ; but when this is accomplished 
Figs.; 90 and 91 will ordinarily be found none too large to com- 
plete the operation. As the surface of the filling is reached the 
gold should be malleted somewhat beyond the stage where it seems 
dense, on the theory that repeated blows harden gold and make it 
more resistant, even after compactness has been reached. In going 
over the surface for the last time with the mallet a smooth-faced 
plugger may be used, and the blows so arranged that the final ones 
are invariably struck along the margins. 

For finishing the incisal aspect of these fillings a sand-paper disk, 
held to position with a ball burnisher, will quickly dress the filling 
to form, after which it may be polished with a fine cuttle-fish disk. 

Fillings in Proximo-Occlusal Cavities in Bicuspids and Molars. 

The Matrix. — A necessary concomitant to the proper considera- 
tion of the insertion of contour fillings in bicuspids and molars 
relates to the question of the matrix. A perfect understanding of 
its advantages and limitations should be acquired by every opera- 
tor, in view of the fact that if properly employed under suitable 
conditions it is capable of materially lessening the fatigue and 
difficulty of these operations, while if used ill-advisedly or un- 
skillfully it leads to the gravest defects in the work and proves 
simply a delusion and a snare. 

The chief office of the matrix is to supply the missing wall of a 
cavity, thus converting a proximal cavity of three walls into one 
of surrounding walls. This becomes a matter of very great im- 



INTRODUCTION AND FINISHING OF GOLD FILLINGS. 205 

portance in distal cavities far back in the moutli, on account of 
the angle at which a plngger must approach such cavities. Unless 
there is a supporting matrix-wall against which to build the gold, 
the filling must either be made unnecessarily full while it is being 
built or else it must fail of adequate density on the proximal sur- 
face. With a matrix properly adjusted, the correct contour can 
readily be given the filling while the gold is being condensed, 
so that little trimming is necessary in finishing, and the surface 
may be made as hard as desired. It will very materially lessen 
the labor and nervous strain of an operation, and will therefore 
well repay the study necessary for its successful use. 

The main objections urged against the matrix may be summar- 
ized as follows: The difficulty of obtaining adaptation of the gold 
into the angle formed by the junction of the matrix mth the mar- 
gin of the cavity thus resulting in imperfect margins to the filling, 
and the obstruction which the matrix is supposed to form to a 
good view of the cavity. Each of these objections is well founded 
under certain conditions, and each is equally inoperative under 
certain other conditions. If a thick, stiff matrix is used and 
tightly wedged against the cavity outline, it will be found difficult 
to properly carry the gold over the enamel-margin and secure a 
perfect sealing of the cavity, but if a matrix is made of a thin, 
springy material, capable of being forced away from the cavity- 
margin at will, so that the gold may be carried between the 
matrix and the margin, there is really no obstacle in the way of 
doing perfect work. In fact, the proper use of the matrix wdll fa- 
cilitate the making of good, dense margins to our fillings with less 
difficulty in these distal cavities than where the attempt is made to 
build the filling in an open cavity. The matrix is a support to the 
gold during condensation, and it has a sustaining influence to hold 
the filling to form under the impact of the plugger. If a mallet 
blow is used on the gold in the direction in which it is often neces- 
sary in these cavities far back in the mouth, the tendency is to force 
the gold away from the cavity-margins, imless there is some sus- 
taining wall against which to build. This matrix-wall keeps the 



206 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

gold up to its place and gives the opportunity for free malleting 
without rolling the gold away from the axial wall and margins. 

This does not imply that the greatest care is not always neces- 
sary in the use of the matrix. As has been intimated, no matrix 
should be used which is not capable of being forced by the plugger 
sufficiently away from the cavity to admit a mat of gold between it 
and the margin. Given a matrix which on adjustment fits ap- 
proximately to the margins of the cavity, the aim should be, in 
placing the first pieces of gold over the gingival wall, to so force 
back the matrix with the plugger that it will stand away from the 
buccal and lingual margins at least half a millimeter, and this 
space should be maintained throughout the building of the filling. 
If this is done the margins may be readily covered and the gold 
made dense and perfectly adapted. 

The objection as to the obstruction of light and vision from the 
cavity holds good if a broad matrix be used on a mesial cavity, but 
there is no obstruction whatever on a distal cavity. In view of the 
fact that there is seldom any necessity for a broad matrix on a 
mesial cavity, the question becomes one of judgment in the selec- 
tion of suitable cases for the matrix rather than one bearing on a 
fundamental objection to the appliance itself. The most that is 
ever required in the way of a matrix on a mesial cavity is a narrow 
strip of metal placed across the gingival third of the cavity to give 
form to the filling in the interproximal space and provide a guid- 
ing wall against which the filling may be so built that it will 
require very little subsequent trimming in finishing it. This does 
not materially obstruct the view of the cavity, and it furnishes all 
that is necessary in the way of a matrix for these cavities. 

Another objection which is sometimes urged against the matrix 
may be mentioned merely to controvert it, — viz, the difficulty of 
securing adaptation of gold to the surface of the matrix. The 
claim is made that in building gold against a matrix it is seldom 
that a filling is perfect on the proximal surface owing to spaces 
being left here and there as the gold is laid against the matrix. 
If this be true, it is due to either one of two things, — an oversight 
on the part of the operator or improperly formed pluggers. That 



IXTKODUCTION AND FIISriSHING OF GOLD FILLINGS. 



207 



gold can be perfectly adapted to a surface like the matrix has been 
too often demonstrated to require further emphasis. It is surely as 
easy to adapt gold to a matrix as to the wall of a cavity, and it is 
safe to conclude that in many of the cases where the surface of the 
jSlling next to the matrix has been found defective the surfaces next 
to the walls of the cavity would present similar imperfections, if 
the same facilities for examination were available. The chief dis- 
tinction between building gold against the flat surface of a matrix 
and the flat surface of a cavity is that the former is somewhat more 
disastrous to plugger points than the latter, the serrations being 
more rapidly battered down when coming in contact with steel 
than with dentine or enamel. 

The Kind of Matrix. — lio one form of matrix may be deemed 
available for all cases, and in some instances it will be found desir- 
able to improvise a matrix specially for the case in hand. The 
band matrices made of thin steel, such as the Brophy matrix (Fig. 
92), serve an excellent purpose for ordinary work, though they are 

Fig. 92. 




not universally applicable. The material of which these matrices 
are made is almost ideal for the purpose. The steel is sufficiently 
rigid to sustain the gold against thorough malleting, and yet its 
springy nature admits of its being forced away from the cavity- 
margins by pressure of the plugger. There are some objections to 
these matrices which occasionally assert themselves, chief of which 
may be mentioned the fact that in bell-crowned teeth the matrix 
embraces the tooth tightly near the occlusal surface and stands 
some distance away from the neck along the gingival half of the 
cavity. This objection may readily be overcome by packing some 



208 PBINCIPLES AND PKACTICE 0¥ FILLING TEETH. 

gutta-perclia into the interproximal space between the matrix and 
the proximating tooth, so as to force the matrix up to the gingival 
margin of the cavitj. Wooden wedges have sometimes been advo- 
cated for this purpose, but the danger with these is that the wedge 
is likely to force the matrix too close to the margin, and the wood 
is so unyielding that the plugger cannot press the matrix back to 
allow the gold between it and the margin. "With gutta-percha the 
matrix may be carried as close to the cavity as desired, and the 
material will be found sufficiently yielding to admit of manipula- 
tion by the plugger so as to secure perfect protection to the cavity- 
margins. 

Another difficulty sometimes encountered with the band matrix 
is the problem of maintaining it in position on teeth that are more 
cone-shaped than bell-crowned, — ^where the axial surfaces slope 
from the gingival line to the occlusal surface in such a way as to 
present an inclined plane along which the matrix slides to its dis- 
placement. Occasionally this may be prevented by packing hot 
gutta-percha between the matrix and the buccal and lingual sur- 
faces of the teeth and letting it cool before there is any manipula- 
tion of the matrix. If the gutta-percha is quite hot, it will be more 
or less adhesive both to the matrix and the enamel, and it will 
often prove effective. In cases where this will not answer cement 
may be substituted, though this requires so much time for its appli- 
cation and crystallization that it is indicated only in those cases 
where nothing else will suffice and where such a matrix seems to 
be especially demanded. 

Another feature of the band matrix calls for attention so far as 
the comfort of the patient is concerned. In very many of the 
cases where a matrix is indicated it will be found that the decay 
has extended so far rootwise that the gingival margin of the cavity 
is some distance beyond the original free margin of the gum. 
This tissue has consequently either receded or been forced out of 
the way with gutta-percha in the manner already described in the 
consideration of cavity preparation. Under these conditions the 
gum in the adjoining interproximal spaces extends much farther 
crownwise than that in the affected space, and if the matrix is 



INTRODUCTION AND FINISHING OF GOLD FILLINGS. 209 

carried sufficiently rootwise to cover the gingival margin of the 
cavitv, — which it must be in order to prove effective, — that portion 
of the band in the adjoining interproximal space impinges forcibly 
on the gum-tissue, to the serious discomfort of the patient. The 
only remedy for this is to cut away the edge of the band which 
passes into the adjoining space in such a manner that a considerable 
concavity is presented to the gum instead of a convexity, and this 
should be done with all band matrices, even though it involves 
the necessity of having a separate set for each side of the mouth. 

When it becomes desirable to make a matrix for the special case 
in hand, a suitable material for the purpose is found in copper or 
German silver rolled thin. This may be wrapped around the 
tooth and fashioned with a burnisher to any desired form, and the 
two ends tacked together with solder. 

The narrow matrix for the interproximal space in the manage- 
ment of mesial cavities may be conveniently made from an old 
watch-spring. This should be broken into lengths varying from a 
third to half an inch for the different sized teeth, and then ground 
convex on one edge so as to dip down into the space with the con- 
vexity looking rootwise. The varying degrees of curve to the 
spring may be utilized in the selection of suitable forms for the 
different teeth. For instance, a lower second bicuspid which is 
nearly round at the neck would call for a matrix made from near 
the center of the spring, where the curvature is greatest, while for 
a molar with a broad proximal surface the matrix should be made 
from the periphery of the spring, where there is little curve. 
These matrices may be slipped between the teeth and held in place 
ordinarily by their own form, the convexit}" of the curve resting 
against the proximating tooth just rootwise of the contact point. 
If the space between the teeth is so great that they will not remain 
of their own accord, they may be fastened with gutta-percha, as 
already described. When the filling is completed, this form of 
matrix should be removed by forcing it either buccally or lin- 
gually, it being ordinarily impossible to remove it occlusally. 

Manner of Using a Matrix. — The greatest care should be exer- 
ci.sed in securing a proper adjustment of the matrix to the end: 

14 



210 PRINCIPLES AND PEACTICE OF FILLING- TEETH. 

that it shall be maintained in position during the condensation of 
the gold, and that it shall have such a form that when the filling is 
built against it the proximal surface of the filling will present a 
contour that requires little trimming. The matrix should dip in 
close to the tooth at the gingival region of the cavity, and stand out 
tight against the contact point of the proximating tooth near the 
occlusal surface. If it does not take this position when applied to 
the tooth, it should be forced to take it by packing gutta-percha in 
the interproximal space, as previously suggested, and by burnish- 
ing the free end of the matrix against the proximating tooth. 
One of the prime advantages of the matrix is that by its use a fill- 
ing may be so malleted as it approaches the contact point of the 
proximating tooth that the contact point on the filling is given 
the greatest possible density without building any excess of mate- 
rial. The matrix should be so thin that when the filling is con- 
densed and the matrix removed there is practically no space left 
and the gold falls against the proximating tooth. By the use 
of the matrix a tooth may be filled and the proper contour main- 
tained with less separating than where no matrix is used. 

Before placing any gold in the cavity it is well to go along the 
matrix-wall with a plugger and test it, to see if it may be pressed 
away from the cavity-margins at will. If there is any point where 
it seems too rigid, so that there is likelihood of an oversight in 
adapting the gold, this portion of the matrix should be forced away 
from the margin in advance of the operation, to make certain of 
a ready overlapping of the gold. 

When the matrix is satisfactorily adjusted, the filling may be 
started by introducing a rope of non-cohesive gold along the gingi- 
val wall and wedging it into the angle between the gingival and 
axial walls, and also locking it into the gingivo-buccal and gingivo- 
lingual angles. When the first part of the filling is thus securely 
fastened in position, the gold should be carefully condensed over 
the gingival border of the cavity by forcing the matrix slightly 
away from the margin with the plugger and slipping the gold in 
between the margin and the matrix. This may readily be done 
with a plugger formed like that in Fig. 86, placing the serrated end 



INTRODUCTION AXD FINISHING OF GOLD FILLINGS. 211 

on the gold and tipping the shank against the matrix to force it 
back. When this is successfully accomplished along the entire 
gingival margin, and the non-cohesive gold is covered by a layer 
of cohesive pellets, the mallet may be used to secure thorough con- 
densation over the whole area of gold, and especially at the junc- 
tion of the gold with the matrix. The plugger should be carried 
step by step along the matrix-wall until the filling is hard and 
dense. If this precaution is taken throughout the operation, and 
if the gold is not laid on in too large masses, there will be no doubt 
about the uniformity of density on the proximal surface of the 
filling. 

To secure the best results in building against a matrix, the 
pellets should be laid with their sides to the matrix and their ends 
looking buccally and lingually, while the filling should be kept 
nearly horizontal. 

As has already been intimated, from the time the first pieces of 
gold have been forced between the matrix and enamel the appli- 
ance should be kept sufficiently away from the cavity dur- 
ing the operation to admit of carrying the gold well over Fig. 93. 
the peripheral enamel-margin. (Fig. 93.) AVitli these 
precautions there is no need for poor work with the matrix, 
but unless an operator is prepared to give close attention 
to the points indicated he would better dispense with the 
appliance altogether. It is an appliance which if abused 
cr misunderstood is exceedingly treacherous, and will result in 
very faulty work, but if used with judgment and care it is capa- 
ble of materially lessening the strain of these complicated opera- 
tions, and will prove a source of great satisfaction to the operator. 

The plan of building these occluso-proximal fillings will be con- 
sidered in greater detail under the heads of the different cavities. 

Disto-Occlusal Fillings in Left Lower Bicuspids and Molars. 

With the matrix in place a rope of non-cohesive gold of suitable 
size should be grasped with the pliers and one end carried into the 
gingivo-lingual angle, and the rope folded on itself at convenient 
intervals along the gingival wall toward the buccal wall. If the 



212 PEINCIPLES AND PKACTICE OF FILLING TEETH. 

rope is not of sufficient length, to reach entirely to the buccal wall 
when thus folded, another rope should be started in the gingivo- 
buccal angle in the same way and the two ropes joined. "VVitb a 
mass of non-cohesive gold thus laid along the gingival wall, the 
condensation should begin by taking a square-faced plugger with 
a serrated area as broad as the width of the gingival wall mesio- 
distally, and bringing it down on the gold with hand pressure 
toward the gingivo-lingual angle. A plugger of this size will 
carry the gold ahead of it instead of puncturing it, as would be the 
case v/ith one of too limited area; and if operated in the swaying 
motion already described it will insure perfect adaptation of the 
gold without the rope following the plugger out of the cavity. 

When the plugger has been brought to bear on the non-cohesive 
gold at several points along the gingival wall, so as to compress the 
gold partially into position, a cylinder of cohesive gold wide 
enough in diameter to reach from the axial wall to the gingival 
enamel-margin should be laid in the gingivo-lingual angle with its 
side upon the gold already in place and one end looking along the 
gingival wall, while the other is slightly tipped up against the 
lingual wall and looks along this wall. This should be forcibly 
driven into the structure of the non-cohesive gold in the direction 
of the gingivo-linguo-axial angle by hand pressure with a smaller 
plugger exerted in the swaying motion, and when securely pinned 
into place, by bringing the plugger to bear on it at several points in 
this manner, another cylinder may be laid a little farther along the 
gingival wall toward the buccal wall, but still lapping the cohesive 
cylinder already in place. This process should be continued with 
hand pressure till the cohesive gold reach.es across the gingival wall 
to the buccal wall, and especial care should be taken to force the 
last cylinder so placed securely into the gingivo-buccal angle. 
When the filling is thus locked in position the mallet may be used 
to condense the entire mass, starting the plugger at either the 
gingivo-linguo-axial angle or the gingivo-bucco-axial angle, as the 
case indicates, and carrying it step by step across the cavity, direct- 
ing it first along the gingivo-axial angle. The object is to secure 
the greatest degree of adaptation and density in this angle, to the 



i:!^TRODUCTION AISTD FINISHING OF GOLD FILLINGS. 213 

end that the filling- may be so seated in position that there is no pos- 
sibility of subsequent movement from manipulation. A con- 
venient form of plugg'er for this purpose is found in Fig. 86. 

After density is gained along the gingivo-axial angle a broader- 
faced plugger may be used to condense the remaining gold, pro- 
vided the area of the gingival wall is great enough to call for it. 
Usually in bicuspids the width of the gingival wall mesio-distally 
is so limited that the form Fig. 86 is as large as can well be used. 

When the gold is thus malleted down upon the gingival wall the 
plugger should be directed into the angle formed by the junction 
of the matrix with the margin of the cavity, and the gold should be 
carried against the matrix and over the entire gingival margin. 
This will force the matrix slightly away from the margin as pre- 
viously advised, and insure perfect adaptation of gold over the 
enamel. 

The operation now presents with the gingival portion of the fill- 
ing in place, a cushion of non-cohesive gold lying against the 
gingival wall with a layer of thoroughly condensed cohesive gold 
covering it, and the whole mass securely seated on the gingival wall 
and locked between the buccal and lingual walls. A filling thus 
started in a cavity of proper form cannot by any means be made to 
rock or loosen with subsequent manipulation. It is firmly seated 
on a flat base and supported laterally by pei-pendicular walls, so 
that there is no possibility of tipping, provided the gold has been 
well adapted and made dense. The virtue of creating angles to 
join the walls of these cavities, as advocated in considering their 
preparation, is now especially apparent to the operator as he starts 
the filling. There is a sense of security to his work obtainable in 
no other way. 

The building of the filling from this stage to the point where the 
proximal portion of the cavity joins the occlusal anchorage step 
is simply a process of laying the cohesive cylinders on the gold 
already in place with their ends looking buccally and lingually, and 
malleting firmly to place. These cylinders should be wide enough 
to reach from the axial wall to the matrix, and the filling should 
be kept as high along the matrix as along the axial wall. When 



214 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

a cylinder is placed near tlie buccal or lingual wall the Qnd should 
be turned slightly up against this wall, so that when condensed it 
will leave the filling a trifle higher along these walls than at other 
points. This is to insure the possibility of directing the plugger 
against these walls, and also to avoid the danger of leaving a 
pocket between the condensed gold as it approaches the occlusal 
surface and any possible overhang which may exist in the cavity at 
this point. This overhang relates to two conditions, either where 
it has not been possible to make the cavity as wide bucco-lingually 
at the marginal ridge as at the gingival margin, or where decay has 
so eaten up under the cusps that an arch is formed to the cavity 
under which the gold must be adapted. It is not always possible 
or at all advisable to cut up through this arch so as to create a 
perpendicular wall to the cavity for facility in building the gold. 
Neither of these forms of cavities may be considered ideal, but in 
the mouth we must meet the issue of reality as well as ideality. In 
cavities thus f onned the gold must be kept higher along the buccal 
and lingual walls than at any other point, and if a pocket should be 
encountered on approaching the occlusal aspect of the cavity some 
non-cohesive gold should be wedged into it. 

A modification of this method of building the gold may be ad- 
vantageously followed in those cases where the cavity is broader 
bucco-lingually at the occlusal surface than at the gingival mar- 
gin. In such cavities the buccal and lingual walls diverge as they 
approach the occlusal surface, thus presenting an open aspect to the 
cavity which renders the buccal and lingual walls easily accessible 
at all points. AVith a cavity so formed the gold may be kept as 
high in the central portion of the filling as at the buccal and lingual 
walls, or it may even be a trifle higher in the center so as to dip 
down slightly toward these walls. Into the angle thus formed 
between the walls and the filling cylinders may be so wedged as 
to most effectively lock the gold between the buccal and lingual 
walls, and lend a security and solidity to the filling unattainable 
in any other way. 

When the filling is level with the anchorage step on the occlusal 
surface a cylinder should be laid with ends looking mesially and 



INTEODUCTION AKD FINISHING OF GOLD FILLINGS. 215 

distally, one half over the gold already in place and the other 
extending into the step. After this is condensed another cylinder 
should be laid in the same way a little farther along the step, but 
still lapping the condensed gold, and this process continued till the 
base of the step is covered. By this arrangement of the cylinders 
the proximal portion of the filling is most securely locked into 
the step. The malletiug should be especially thorough along the 
angle formed by the base of the step with the surrounding walls, 
and from this point to the completion of the filling each cylinder 
should be carefully laid on its side precisely at the point where it 
is intended to condense it; and this cylinder should be made per- 
fectly compact before another is added. This conduces to an even 
and uniformly dense surface to the filling. 

As has previously been intimated, there is one point in building 
these fillings which requires especial attention with relation to its 
density. While the gold is being built against the matrix-wall, 
and the matrix is thus forced against the contact-point of the 
proximating tooth, the greatest care should be exercised in mal- 
leting the gold firmly against the matrix in this region to insure a 
hard, dense contact point on the filling. The ability to accomplish 
this with ease forms a not unimportant argument in favor of the 
matrix for these distal fillings. 

Pluggers. 

The form of plugger found most serviceable for carrying the 
non-cohesive gold to ])lace in starting the filling is found in Fig. 94. 
This plugger is large enough to carry the non-cohesive gold in 
front of it instead of puncturing it. The serrations are compara- 
tively coarse and deep, thus leaving an indented surface on the 
gold to facilitate the interlacing of the cohesive with the non- 
cohesive. The shank is heavy and rigid, permitting of great force 
without springing; and the curve is such that the gingival wall of 
most cavities can readily be reached with it. 

For forcing the first pieces of cohesive gold to place in the angles 
Fig. 80 is admiral>]y adapted, and in cavities which are narrow 
mesio-distally mo.st of the filling may be built up with it. It is 



216 PRINCIPLES AND PRACTICE OF FILLING TEETH, 

also especially useful along the matrix-wall. In cavities of broader 
area the form illustrated in Fig. 95 may be utilized, except for the 
angles or against the matrix. These rounded forms are not in- 
dicated along straight perpendicular walls, but for building the 
main body of the filling they are sometimes very useful. 

In cavities far back in the mouth the curve in Fig. 95 will not 
always be found great enough, and in this event Fig. 96 may be 
utilized. This will reach where Fig. 95 will not. But even with 
this plugger there are many places in these distal cavities which 
cannot be reached with mallet force at all, and then resort must be 

Fig. 94. 
E3 




had to right-angle pluggers and hand pressure. A convenient size 
for this is shown in Fig. 97. This plugger may be used along the 
buccal and lingual walls of these cavities, and, in fact, in any 
position not accessible to mallet force. 

One great aid to the building of these disto-occlusal fillings on 
the left lower teeth relates to the position taken by the operator. 
It is frequently of the greatest possible advantage to go around to 
the left side of the patient and approach the cavity from this as- 
pect. This will often bring the cavity into more perfect view and 
give better access with the plugger. The lingual wall will ordi- 
narily by this means be so presented to the operator that he can 
mallet his gold directly against it. 

The point of all others where failure in adaptation to walls is 
most often manifest in these — as, in fact, in all disto-occlusal cavi- 



INTRODUCTION AND FINISHING OF GOLD FILLINGS. 217 

ties on the lower teeth — is along the wall which stands nearest to 
the operator. The lingual wall on the left side of the mouth often 
suffers in this particular unless the operator avails himself of the 
advantage of condensing from the left side of the patient at such 
intervals in the work as may seem desirable. This practice will 
also be found effective in those cases on the molars where the 
occlusal portion of the cavity involves the fissures so as to extend 
across the tooth bucco-lingually and pass between the mesial and 
distal cusps., The wall of the cavity which stands nearest the 
mesio-lingual cusp cannot be reached by mallet force from the 
right side of the patient, but by passing to the left the operator 
may get convenient access to it. In w^orking from the left side the 
mirror should be used in the left hand, to hold back the angle of 
the mouth and reflect light into the cavity, while the plugger is 
being used in the right. The pluggers indicated for this work 
must be suggested by the demands of the particular case, but or- 
dinarily such forms as Figs. 86 and 96 wall be found effective. 
The latter is especially useful in building the bulk of many of these 
large fillings, on account of the reach occasioned by the curve m 
the shank and the angle at which it is thus possible to present the 
serrated end to the gold. 

Finishing the Filling. 

When the matrix is removed a thin burnisher should be used to 
go along the margins and press down the slight excess of gold over 
the enamel, after which a narrow finishing strip may be passed into 
the interproximal space and the gingival portion of the filling 
dressed even with the surface of the tooth. On account of the 
close contact, it will ordinarily be found impossible to force this 
strip between the teeth from the occlusal aspect, in event of which 
it may be passed end-foremost into the space from the buccal as- 
pect. When the ends are drawn forward in the mouth they are 
readily grasped by the fingers of the operator, and are more con- 
veniently manipulated than is possible where an attempt is made to 
use a strip on a mesial filling. The strips used should be narrow 
enough to play back and forth in the space without danger of dress- 
ing down the contact ]tiiiiit. 



218 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

When the gingival portion of the filling is perfectly finished, a 
sand-paper disk may be used in the engine to play along the buccal 
and lingual margins as they approach the occlusal surface and 
dress the filling even with the surface of the tooth, but the disk 
should not be allowed to pass between the teeth, through danger 
of cutting down the contact point and creating a flat surface. The 
disk may also be used to advantage to smooth that portion of the 
occlusal surface of the filling which slopes from the contact point 
up toward the cusps, by tipping the disk slightly and forcing it into 
position with a ball burnisher. 

To polish the proximal surface of the filling immediately at 
the contact point a broad, fine finishing strip should be used, 
merely with the object of smoothing the gold, without cutting it 
away. If the filling is so tight against the proximating tooth that 
even a thin strip cannot be passed between the teeth, a separator 
may be employed to gain the slight space necessary, or, if this is not 
practicable, the broad, thin burnisher previously mentioned in con- 
nection with the finishing of proximal fillings in incisors may be 
forced between the teeth and manipulated with a rotating motion 
till the gold is burnished smooth and the way cleared for the intro- 
duction of the polishing strip. This broad burnisher will be found 
very serviceable in all these contour fillings where contact is close, 
and it should be in the hands of every operator. 

When the proximal surface of the filling is thus dressed to 
form and polished, the rubber dam should at once be removed and 
the occlusal surface ground to form with corundum stones kept 
moist. The patient should be instructed to close the jaws fre- 
quently to test the necessary fullness to which the filling may be 
left Avithout interfering with the occlusion, and in the event of a 
sharp cusp from the opposing tooth striking so far into the filling as 
to necessitate grinding it too thin, it is always advisable to shorten 
the cusp of the opposing tooth somewhat rather than make the 
filling weak and render the filled tooth subject to the danger of 
being split in mastication. When the filling is ground to the 
proper form with the stone it may be finished with a moose-hide or 
rubber point carrying moistened pumice till all the scratches left 



INTEODUCTION AXD FINISHING OF GOLD FILLINGS. 219 

by the stone are removed, after which a high polish may be given it 
with whiting. 

Disto-Occlusal Fillings in the Right Lower Bicuspids and Molars. 

The same general plan of building these fillings may be followed 
as has been suggested for the left side of the month, except in one 
important particular. The buccal wall of these cavities on the 
right side of the mouth is almost invariably inaccessible to mallet 
force, and it would therefore seem necessary to build the filling 
along this wall by hand pressure with a plugger formed like Fig. 
97. This should be grasped in the palm of the hand and the gold 
vigorously pulled against the buccal wall, and particularly into the 
angle formed by the junction of the buccal with the axial wall. 
Occasionally it will be found necessary in teeth far back in the 
mouth to build the entire gingival third of the filling with hand 
pressure, but ordinarily mallet force may be used on all parts of 
the filling from the gingival wall up, except along the buccal wall. 

Another point where right-angle hand pressure is indicated in 
these fillings is in the angle formed by the base of the anchorage 
step and the mesial wall of the step. This is a wall which looks 
away from the operator, and the base of the step cannot be seen 
at this point except with the mirror., It is therefore impossible to 
reach it with direct mallet force, and the strong right-angle plug- 
ger should be employed to lock the gold into this angle and build 
it up to the point where the mallet blow is effective. Unless this 
precaution be taken, there is quite likely to be a bridging of the 
gold over the angle and a subsequent leak in the filling. 

Disto-Occlusal Fillings in Upper Bicuspids and Molars. 

The plan of building these fillings is practically the same as for 
lower teeth, except that mallet force may be more uniformly used 
here than on the lower jaw. Except in rare cases, the only place 
where the mallet may not be used after the filling is started is along 
the buccal wall of cavities on the left side of the mouth. Here 
it is often necessary to work by the aid of the mirror and adapt 
the gold with a large right-angle plugger grasped in the palm. 



220 PBINCIPLES AND PRACTICE OF PILLING TEETH. 

For the bulk of the work, when the filling has reached the point 
where mallet force may be used, such forms as Figs. 86, 95, and 96 
will be found effective. 

Mesio-Occlusal Fillings in Bicuspids and Molars. 

The same arrangement of gold may be followed in building these 
fillings as for disto-occlusal surfaces, except that in mesial fillings 
mallet force is almost universally applicable. The better access to 
this kind of a cavity would seem to render these fillings more 
easily inserted than distal ones, but there is one counter difficulty 
which becomes important unless it is fully appreciated and the 
proper means taken to avoid it. This relates to the finishing of 
the filling along the gingival third of the proximal surface. As 
has already been stated, it is exceedingly difficult to manipulate a 
strip so as to cut against the mesial surfaces of these fillings. The 
ends of the strip cannot ordinarily be carried far enough back in 
the mouth to work effectively in the cutting of any great surplus 
of gold. The most that can be done is to smooth the filling after 
it is of the proper form. 

It is therefore of the greatest importance that the filling when 
condensed shall present as nearly as possible the form it should 
assume when finished, and to this end a matrix should be used 
along the gingival third of the cavity to give the filling the most 
desirable form while it is being built. A little 
time and care in the proper adjustment of the 
matrix will be amply repaid in tlie facility with 
which such a filling may be finished. In those 
cases where it is found that an appreciable surplus 
of gold has been built over the gingival margin so 
that its removal with the strip would be found a 
tedious and ineffective process, or in the instance 
of a tooth with a concavity on the proximal sur- 
face of the neck, as in an upper bicuspid where 
the strip will not reach, the gold may be dressed 
to form with files or with keen-bladed trimmers. A suitable form 
of file for this purpose is found in the Ehein proximal trimmers 




IXTEODUCTION AND FINISHING OF GOLD FILLINGS. 22 1 

(Fig. 98), which will reach between the teeth into the concavity 
and readily reduce the surplus. The effectiveness of these files 
may be greatly increased if, following a suggestion of the late 
Dr. George H. Gushing, the blades are sharpened and cut with the 
same care that is bestowed on the blades of a bur. Prepared in this 
way they take hold of the gold with a definite grip and peel it off 
rapidly, lea^dng a smooth surface. 

Occlusal Fillings in Bicuspids and Molars. 

The plan of building these fillings varies somewhat according to 
the extent and form of the cavity. A narrow deep cavity calls for 
an arrangement of the pellets of gold different from that of a broad 
and comparatively shallow cavity. In the narrow cavity the en- 
tire area of the pulpal wall or seat may be covered by the first piece 
of gold inserted so that it is wedged between the surrounding walls, 
and the filling may grow from this in regular layers at right angles 
with the long axis of the tooth till the cavity is full. In a broad 
cavity this is not practicable. The filling must be started in one 
extremity of the cavity and carried across the pulpal wall pellet by 
pellet, till a sufiicient number have been placed to reach from one 
perpendicular wall to another. 

The idea in fastening these fillings in position against possible 
dislodgment is to securely lock the gold between the surrounding 
walls of the cavity and into the angle formed by the junction of 
these walls with the pulpal wall or seat. If these angles are 
formed on correct mechanical principles and the pulpal wall is 
made flat, as suggested in considering cavity preparation, the gold 
may be inserted with the greatest facility and the filling anchored 
beyond the possibility of displacement under stress of mastication. 
The wear on these fillings is often very severe, and the gold, in 
order to do the most permanent service, must not only be perfectly 
adapted to the walls, but must be made dense and hard. As has 
already been stated, the hardness of gold can be largely increased 
by continued malleting, even after compactness has been reached, 
and in the insertion of these fillings the operator should take advan- 
tage of this fact in order to secure as perfect a wearing surface to 



222 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

his fillings as possible. As the last pieces of gold are added the 
malleting should be carried somewhat beyond the point of compact- 
ness, until the operator can detect a hard, metallic ring to the sur- 
face of the filling. This does not imply prolonged or injudicious 
hammering on the gold to the injury of the peridental membrane 
or the enamel-margins. Care should be exercised not to go beyond 
the necessities of the case, but the idea should ever be present that 
these fillings, more than all others, require the greatest density and 
the highest degree of resisting power. 

If an operator will consider carefully the amount of aggregate 
service which such a filling is likely to be called upon to perform in 
the course of its allotted life, he will be more seriously impressed 
with the necessity for the greatest care and thoroughness in its 
condensation. The repeated impact in the process of mastication 
aggregates enormously in a single year, and a filling inserted in 
the mouth of an individual of early or middle life with an expect- 
ancy of twenty, thirty, or even forty years' service must needs be 
of the highest order of excellence to meet the requirements. As 
has already been intimated, the proper mastication of an ordinary 
meal involves at least one thousand occlusions. Supposing that 
the force of one-half or even one-fourth of these falls on a certain 
tooth, the number of impacts on that tooth in the course of a 
twelvemonth is seen to be very great. Multiply this by the num- 
ber of years such a tooth is likely to be called on for service, and 
the sum becomes well-nigh appalling. The force of these impacts 
varies in different mouths, and there is also a considerable range 
in the degree required for the comminution of the different kinds 
of food material in the same mouth; but the lowest force neces- 
sary for ordinary mastication is at least great enough to become 
an important factor in determining the degree of density required 
of a filling against which it is brought to bear. 

In an extended study of the greatest possible force that could be 
exerted by closure of the human jaws, Dr. G. V. Black found that 
upon the molars it ranged from twenty-five pounds to three 
hundred pounds, and that the force in common use in mastica- 
tion was greatly in excess of preconceived ideas on the subject. 



INTRODUCTION AND FINISHING OF GOLD FILLINGS. 223 

Suppose, then, a filling on the occlusal surface of a lower molar 
with the cusp of an upper molar occluding directly against it, and 
this filling at each meal receiving the impact of the upper cusp 
crushing food-material between it and the filling at the rate esti- 
mated, it will readily become apparent that to do permanent service 
the material of which the filling is made must be capable of with- 
standing considerable wear. 

The reason that many fillings of poor structure have been known 
to save teeth for years is accounted for in the fact that they have 
been so situated with relation to the opposing tooth that the par- 
ticular filling in question has not received the full force of masti 
catory usage, but such a possible contingency as this should not 
deter an operator from making his fillings uniformly of the highest 
degree of excellence. If we could have the record of all the fill- 
ings which have failed as the result of imperfect condensation, and 
place it beside the number of such fillings that have succeeded, the 
evidence would be overwhelmingly in favor of dense fillings. 

Insertion of Gold in Occlusal Cavities in Lower Molars. — 
Usually these cavities are so large in area that the gold must be 
started in one extremity of the cavity and carried across the pulpal 
wall toward the other extremity piece by piece, instead of wedging 
from one wall to the other at the beginning. Fillings of this char- 
acter should ordinarily be started in that portion of the cavity most 
remote from the operator, and built progressively toward the wall 
nearest him. A rope of non-cohesive gold should first be carried 
into the angle formed by the junction of the distal wall of the 
cavity with the pulpal wall or seat, and into this non-cohesive gold 
should be forced a cylinder of cohesive gold and the whole mass 
driven to place with hand pressure, followed by the mallet. The 
cohesive cylinders should now be added one after the other, with 
their sides against the mass of gold already in place, and each 
cylinder condensed by mallet force over its entire surface. The 
ends of the cylinders should look toward the pulpal wall and the 
occlusal surface of the filling, except that as the filling is being 
built forward the portion near the pulpal wall should be slightly 
in advance and extend farther toward the mesial than that at the 



224 PEijsrciPLES and practice of filling teeth. 

occlusal surface. This presents an inclined surface of gold to the 
operator against which the plugger point may have a direct bear- 
ing, and the cylinders should be laid with their sides upon this 
incline. Each cylinder should be long enough if possible to reach 
from the pulpal wall to the extreme elevation of the occlusal sur- 
face of the filling. 

As the point is reached where the cavity widens out buccally 
and lingually between the mesial and distal cusps, care should be 
exercised to wedge the gold securely into the angles formed by the 
junction of the pulpal wall with the lingual and buccal extremities 
of the cavity. These portions of the filling are sometimes lifted 
out of place by the use of adhesive materials such as sticky candy, 
etc., unless the precaution is taken to so deepen the cavity at these 
points as to afford ample retention, and then condense the gold 
firmly into place. 

There are two points from this to the completion of the filling 
which demand especial attention, — the wall which looks toward the 
mesio-lingual cusp on left lower molars and the mesio-buccal cusp 
on right lower molars, and also the mesial extremity of cavities on 
either side of the mouth. Unless the operator be very cautious, 
these places will be bridged over and the filling fail of perfect 
adaptation and density. As has already been intimated, the diffi- 
culty of approaching these walls by mallet force on the left side of 
the mouth may be largely overcome by operating from the left side 
of the patient, but on the right side there is no alternative except 
to use curved pluggers and pull the gold into position. 

When the walls are protected and the filling built flush with the 
masticating surface, the entire area of exposed gold should be 
thoroughly malleted to perfect density. This may be done with 
pluggers of shallow serrations or no serrations at all, and the final 
blows of the mallet should be struck along the margins of the 
filling. 

Insertion of Gold in Occlusal Cavities in Upper Molars. — 
These cavities are usually of such an area that the first piece of gold 
inserted may be made to cover the entire pulpal wall so as to wedge 
between the surrounding walls, A non-cohesive rope of sufficient 



INTRODUCTION AND FINISHING OF GOLD FILLINGS. 225 

Size to fill about one-third of the cavity should be used to start the 
filling, and into this the cohesive cylinders may be interlaced till 
the two forms of gold are locked together. When the filling is 
nearly completed the cylinders should be carefully laid in regular 
layers, with their sides upon the filling already in place, and con- 
densed with pluggers having shallow serrations, to the end that the 
surface of the filling may be made uniformly dense and even. 

In those long, narrow fissure cavities, such for instance as those 
which follow the disto-lingual groove, the filling should be started 
in one extremity of the cavity and built progressively across to the 
other extremity, but the same principle of wedging the gold be- 
tween the two lateral walls of the cavity should be followed 
throughout. The fact should never be lost to view that in the 
insertion of all gold fillings, no matter where located, the prime 
requisite for success is adaptation of the gold to the walls. This is 
more important, if possible, even on these occlusal surfaces, than a 
high degree of density, and yet the thorough and careful operator 
will not stop short of securing perfect adaptation and high density. 

Insertion of Gold in Occlusal Cavities in Bicuspids. — The 
most difiicult fillings to insert successfully on any of the occlusal 
surfaces are those in the small round pit cavities sometimes found 
on lower bicuspids. They appear to be the simplest possible form 
of cavity to fill, and yet they really demand a higher order of skill 
than cavities of much larger area. Unless the cavity has well- 
defined angles and a flat pulpal wall the gold has a tendency to roll 
under pressure, and there seems to be an especial difficulty, par« 
ticularly with beginners, in securing good adaptation to the walls of 
these round holes. Then in some instances the occlusal portion of 
the filling is inclined to loosen as the final malleting is being done 
and come away from the gold in the depth of the cavity, leaving a 
little peg of gold to which it seems almost impossible to attach any 
fresh gold. 

The proper method of inserting these fillings is to use a mass of 
non-cohesive gold of sufficient size to fill at least one-half of the 
cavity, and force a round plugger slightly less in area than the 
cavity into the center of the mass and wedge it in every direction 

15 



226 PRINCIPLES AND PEACTICE OF FILLING TEETH. 

with hand pressure wielded in the swaying motion before referred 
to. This leaves a depression in the middle of the filling, with some 
non-cohesive gold standing up against the surrounding walls of the 
cavity. A small cylinder of cohesive gold should now be wedged 
into the depression in the non-cohesive gold with hand pressure, 
and the whole mass forced in all directions, — toward the pulpal 
wall and against the surrounding walls. The pressure should be 
very vigorous, but the manipulation must not be kept up too long 
through fear of overworking the surface and rendering it difiicult 
to attach more gold to it. Most of the filling should thus be built 
up by hand pressure on the wedging principle, and the mallet used 
only on the immediate surface. If this plan be followed the 
operator will secure good adaptation to the walls through the 
medium of the non-cohesive gold, and the two kinds of gold will 
be so wedged or interlaced together that the surface of the filling- 
will not flake off. 

In cavities long and narrow, such as are ordinarily found on 
upper bicuspids and on lower second . bicuspids, the method of 
inserting the gold is the same as for similarly formed cavities on 
molars. The gold should be started in the distal region of the 
cavity and built across to the mesial. The point in these fillings 
requiring especial care in adaptation is in the angle formed by the 
junction of the mesial with the pulpal walk Unless the operator 
watch this angle carefully, he will be likely to bridge the gold over 
it and leave an imperfection in the filling. 

Finishing Gold Fillings on the Occlusal Surfaces of Bicuspids 
and Molars. — As soon as the filling is thoroughly condensed it is 
ordinarily well to remove the rubber dam before finishing. The 
operator should make it a rule not to encumber his patient longer 
than possible with this necessary but disagreeable adjunct to the 
operation, especially in view of the fact that these fillings can 
usually better be finished without it. The most effective means of 
dressing the filling to form is by the use of corundum stones in the 
engine, and these should invariably be kept moist to facilitate the 
cutting of the stone and to prevent heat. The form of stone best 
adapted for most cases is the wheel, and they should range in sizes 



rNTKODUCTION AND FINISHING OF GOLD FILLINGS. 227 

from a very large, thick wheel to a small, narrow form to meet the 
varying cases presented. Care should be taken to test the occlusion 
by repeated closure of the teeth, to be assured that the filling is not 
left so high that an opj)osing cusp impinges too hard upon it. 

^VTien the filling is ground to the desired form it will be found 
that the stone has left its surface covered with scratches, which 
must be removed in order to give it a finished appearance. This 
may ordinarily best be done with moistened pumice carried on a 
moose-hide, leather, or rubber wheel, and when the filling is per- 
fectly smooth some whiting may be substituted for the pumice and 
a bright polish given the surface. 

In certain cases these occlusal fillings may be finished to advan- 
tage with sand-paper disks by tipping the disk at an angle and com- 
pressing it into place with a ball burnisher. In fillings of narrow 
area situated in depressions between cusps it is often difficult to 
reach them with stones mthout cutting the surrounding enamel. 
In these cases small finishing burs may be used with short, sharp 
blades to dress the filling to form, when it may be polished with 
pumice and whiting on wood points carried in the engine. In 
other cases these fillings may be advantageously reached by wind- 
ing a short finishing strip on a small slot mandrel in the engine. 

Buccal, Labial, or Lingual Fillings. 

The same principles of inserting the gold apply to these cavities 
that have just been advocated for occlusal fillings, — viz, in all cavi- 
ties of sufficiently limited area the first piece of gold inserted may 
be made to cover the entire pulpal wall and wedge between the 
surrounding walls, and the filling built up in regular layers parallel 
with the pulpal wall, while in cavities too extensive for such an 
arrangement the gold must be started in an extremity of the cavity 
and built across the pulpal wall piece by piece toward the other 
extremity. In either case the chief requisites relate to perfect 
adaptation to cavity-walls and a reasonable degree of density to the 
gold. As the surface of the filling is approached the aim should 
be to lay the cylinders on in a regular order, so as to obtain as 



228 PRINCIPLES AND PEACTICE OF FILLING TEETH. 

nearly as may be an even surface which will not demand much 
cutting to finish it. 

There is one point in the insertion of these fillings which calls 
for especial attention, — the gingival enamel-margin. Great care 
should be exercised as the filling is being inserted to adequately 
protect the margin without building a large mass of gold over it. 
The slightest deficiency of gold at this point jeopardizes the opera- 
tion and mars an otherwise perfect filling, while a great excess of 
gold leads to a peculiarly irksome procedure in its removal. The 
operator therefore should study carefully the outline of the cavity 
as he is inserting the gold, and should aim to reproduce the original 
form of the tooth with just sufficient excess of gold to make cer- 
tain of a perfect finish. A little extra care at this stage of the 
operation will save much time and annoyance subsequently. 

Finishing the Filling. — Usually the most effective means of 
dressing these fillings to form is to employ a sand-paper disk in the 
engine, and for the proper approach of the disk it is ordinarily 
necessary to remove the clamp. But in every instance where possi- 
ble the rubber dam should be left in position till the filling is 
finished, for the purpose of keeping blood and saliva away from the 
disk, and also to afford protection to the gum and avoid its lacera- 
tion. The dam may be held back so as to expose the filling with 
the fingers of the left hand, or by a hand instrument with its point 
pressed against the surface of the tooth rootwise of the gingival 
margin of the filling. The disk should be smeared with vaseline 
or some suitable lubricant to prevent heating the filling, and also to 
allow it to play freely against the rubber dam without cutting or 
catching in it and rolling it up. 

"When the filling is dressed to the proper form a beautiful polish 
may be given it with a cuttlefish disk or with a small rubber cup on 
a mandrel carrying pumice, followed by whiting. Care should be 
exercised in finishing these fillings to avoid as largely as possible 
any undue laceration of the gums. Some slight irritation of the 
free margin of the gum is often unavoidable, and need not be con- 
sidered serious, but when the gum is badly cut or torn it is not 
always reproduced in as perfect a condition as it originally was, 



MA^'IPCLATIOX OF PLATINUM AND GOLD IN FILLING TEETH. 229 

and the healing is sometimes a slow and discouraging process. 
With ordinary precaution the gum may be so protected from injury 
as to entirely recover from the operation in a day or two, and lap 
over the gingival portion of the filling in a healthy pink condition. 



CHAPTER X. 



MANIPULATION OF PLATINUM AND GOLD IN FILLING 

TEETH. 

This material comes to us in two forms from the manufacturer, 
■ — in the rolled form the same as the heavier golds, and in the form 
of folds made from thinner foils. It is a matter of individual 
preference which form is used, though for ordinary work the folds 
will be found a trifle more obedient to the plugger and more easily 
managed than the heavier forms. The folds are about an inch in 
\ddth, and may be cut into strips of a convenient size for the case 
in hand. There are three shades, 1, 2, and 3, the former having a 
predominance of gold and showing a decidedly yellow color on fin- 
ishing, shade 2 containing a larger percentage of platinum and 
showng more of a platinum color than shade 1, while shade 3 gives 
a decidedly gray color almost like pure platinum. The shades may 
be varied in the mouth to suit the case. 

The chief points of distinction between the management of gold 
foil and the management of platinum and gold relate to the an- 
nealing and the method of condensing. Platinum and gold re- 
quires greater care in annealing to the end that it be not in the 
least overheated, particularly if the folds are used and the anneal- 
ing is done in a flame. To pass a strip through the flame in the 
ordinary way will almost invariably result in the ends curling up 
and the gold shade disappearing entirely, leaving a pure platinum 
shade. These ends when thus overheated are harsh, unworkable, 
and wholly unreliable. In every instance where by any inad- 
vertence platinum and gold is so heated as to change color in thia 
way, it should at once be discarded and no attempt made to use it. 
To gain the best results in the manipulation of platinum and gold 



230 PKINCIPLES AND PEACTICE OF FILLING TEETH. 

it should be annealed over mica on the electric annealer, first plac- 
ing a piece of mica on the annealer and allowing a slow steady 
heat to thus reach the material. If placed directly on the an- 
nealer it will sometimes be found that it will turn to a platinum 
color. 

In building the filling with this material the operator must worla 
a little slower and more deliberately than with gold. It cannot 
safely be added in as large masses as gold, nor is it so easily adapted 
to walls or margins. The condensation must be very painstaking 
and precise, small plugger points being used with the serrations 
shallow but sharply cut, and each piece malleted perfectly dense 
before another is added. 

In view of the more exacting nature of the work it is seldom 
advisable to utilize platinum and gold for the entire filling, the 
most satisfactory results being obtained by employing gold for 
starting the filling, and building it to a point along the walls where 
it approaches the exposed surfaces, and then completing the opera- 
tion with platinum and gold. This will materially shorten the 
work and produce the most perfect filling, on account of the more 
ready adaptation of gold to the inaccessible parts of the cavity. 
As the first pieces of platinum and gold are added to the gold 
already in place the smallest plugger points should be used, and 
the utmost care taken to force the platinum and gold into the 
structure of the gold so that the two are incorporated as one mass. 
If this precaution is taken the platinum and gold will never sepa- 
rate from the gold. As the extreme surface of the filling is ap- 
proached the folds should be laid flat upon the filling in precisely 
the place where they are to be condensed, and the malleting should 
be very thorough, with the impact brought to bear step by step 
over every part of the surface area down to the minutest points. 
To omit even the smallest area from this mallet impact means 
that the portion thus overlooked is likely to flake when the filling 
is subjected to wear, and if the operator desires a satisfactory fill- 
ing free from blemishes he cannot give too close attention to the 
surface condensation. 

Platinum and gold, if thoroughly and uniformly condensed, 



MANIPULATION OF TIN AND CxOLD. 231 

will take on a beautiful finish which is not only satisfactory in its 
wearing qualities, but is highly artistic in appearance. In fact, it 
may truly be said that to produce a perfect platinum and gold 
filling is to attain the highest degree of excellence in the art of fill- 
ing teeth. 



CHAPTER XL 

MANIPULATION OF TIN AND GOLD. 

A CONVENIENT method of preparing this material is to take a 
sheet of No. 4 pure tin foil and lay upon it a sheet of No. 4 gold 
foil, cutting these in three equal parts, making strips about an inch 
in width. These strips may then be twisted into ropes and cut into 
suitable lengths for the particular use intended. In twisting the 
ropes it is well to so arrange the layers of foil that the tin will be 
on the outside of the rope, thus resulting in a tougher product and 
one easily adapted to cavity-walls. 

For building the gingival third of deep occluso-proximal fillings 
in bicuspids and molars, as already suggested, the ropes of tin and 
gold may be used much in the same manner that was advocated for 
gold alone, except that the plugger points should be more coarsely 
serrated, and nothing but hand pressure used in forcing the tin and 
gold to place. The ropes should be vigorously wedged to position 
into the angles and between the cavity-walls, the swaying motion 
of the plugger being especially indicated, and the very greatest 
amount of force used consistent with safety to walls and margins. 
One cardinal point in the manipulation of this material should 
never be lost to view, — the danger of ovennanipulation. The 
plugger should be brought down upon it at a given point with slow, 
strong, wedging force, and as large a mass of the material carried 
to place as possible with this one thrust. The next position taken 
by the plugger point should be deliberate and carefully directed, 
and another area of the mass condensed in the same manner. If 
manipulated in this way the material will go to place readily and 
remain there, while the integrity of the resultant mass will not be 



232 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

impaired, but if the material is in the least degree overworked by 
the pkigger it chops up and disintegrates so as to ruin it. Many 
operators have failed to get satisfactory results with this material 
on account of overmanipulation. 

After the requisite amount of tin and gold has been forced to 
position with hand pressure, the surface will present coarse inden- 
tations resulting from the deep serrations of the plugger, and into 
this surface should be incorporated cohesive gold cylinders, using 
the same plugger with hand pressure till the gold reaches from the 
buccal to the lingual wall. As soon as the gold is securely locked 
across between these two walls and interwoven into the tin and 
gold, the coarse plugger should be laid aside and a plugger with 
shallower serrations substituted for it. Up to this point the process 
has been one of wedging with hand pressure and an interlacing of 
the layers of tin and gold together, and also of the gold cylinders 
into the tin and gold. There is no cohesion between the tin and 
gold, nor between this and the cohesive gold, so that they must be 
interwoven in the manner indicated. But from this point the 
mallet should be used and the layer of cohesive gold should be 
very vigorously malleted down onto the tin and gold till the entire 
mass is made compact and dense. From this the filling is com- 
pleted with gold in the ordinary way. 

The finishing and polishing of the tin and gold at the gingival 
margin is in no wise different from that advocated for gold. 

In filling occlusal cavities in bicuspids and molars for children 
with this material, a rope should be selected if possible large 
enough to fill the entire cavity and leave a sufficient surplus for a 
perfect finish. If the cavity is found to be too extensive for one 
rope to fill, care should be taken that the first rope used shall not 
be so large as to carry the filling too near the occlusal surface. In 
other words, the final rope should be allowed to extend sufficiently 
into the cavity to be firmly locked between the surrounding walls 
and be retained by reason of this locking rather than from any 
union between it and the mass already in place. Tin and gold, as 
has been said, is not cohesive, and while the layers may be inter- 
woven to a certain degree, yet the union thus formed cannot be 



MANIPULATION OF TIN AND GOLD. 233 

considered sufficiently secure to hold the final piece in place against 
any appreciable wear. If the operator finds in condensing the first 
rope that it is likely to carry the filling too close to the occlusal sur- 
face, he should tear off a piece and lay it aside so as to leave an ap- 
preciable depth to the cavity before adding the last rope. This use 
of two or more ropes instead of making a single rope of sufficient 
size to fill any of these occlusal cavities is advocated because of the 
unwieldy nature of a rope which is much greater than an inch in 
length. 

In view of the fact that it is seldom advisable to use this ma- 
terial in cavities having a very broad area presented to the occlusal 
surface, on account of the tendency to rapid wear under such con- 
ditions, the usual method of inserting the filling is to wedge be- 
tween surrounding walls, the limit of the cavity ordinarily being 
such as to permit of this plan. The rope should be grasped by 
the pliers about five or six millimeters from the end, and this end 
carried into the cavity so as to fold upon itself against the pulpal 
wall. The rope should then be grasped a little farther back and 
folded again into the cavity, this process being kept up till suf- 
ficient of the rope has been gathered into the cavity to constitute 
an appreciable mass when condensed and permit of being wedged 
between the surrounding walls of the cavity. If the cavity is so 
deep that it will require more than one rope to fill it, the first rope 
may be nearly all carried to place with the pliers before the plug- 
ger is used to condense it, but if only one rope is required the con- 
densation should begin after the first half has been forced into 
place and while the other half is still hanging free from the cavity. 

The manner of condensing is by hand pressure, using a stiff- 
shanked, coarsely-serrated plugger. This should be forced toward 
the pulpal wall in the middle of the mass of material, and then 
vigorously swayed in every direction to carry the material snug 
and tight against the surrounding walls, using as much force in 
these movements as can safely be done short of injury to tooth- 
tissue or the peridental membrane. The same precaution against 
overman ipulation is necessary here as with the gingival portion of 
proximal fillings. When a few vigorous and effective wedging 



234. PRINCIPLES AND PEACTICE OF FILLING TEETH. 

moveraents have been made against the mass, some more of the 
rope should be gathered into position and the wedging continued. 
As the surface is approached the free end of the rope should be 
folded over so as to look toward the pulpal wall, and it should be 
forcibly driven into the mass of filling-material and interwoven 
with it, leaving the looped side of the rope presented to the occlu- 
sal surface. Care should be taken to have the material somewhat 
more than flush with the orifice of the cavity, but this surplus 
should not be manipulated to any extent with the plugger point. 
For the surface condensation a large ball burnisher should be used, 
and the filling vigorously burnished iiito the cavity and against the 
margins till the surface is as hard as this material will permit. 

To dress the filling to form and give it an even surface a fine 
corundum stone may be used in the engine, or in cases of a very 
small filling in a deep depression between cusps where a stone will 
not reach a finishing bur may be substituted. In places where the 
sand-paper disk may be made to reach the filling by forcing it to 
place with a ball burnisher, this will be found the ideal method of 
finishing these fillings. 

The use of tin and gold in these small occlusal cavities in chil- 
dren's teeth is strongly advocated in preference to amalgam. Con- 
trary to the prevailing impression in regard to the matter, it can 
be inserted more expeditiously than amalgam, and if properly 
manipulated it is more certain in its results. It is less treacherous 
than amalgam. If it fails it does so in a manner at once recog- 
nized, while amalgam may appear perfect to the naked eye and 
yet be leaking so badly as to cause the enamel to be undermined by 
decay for a considerable area around the deeper portions of the 
filling. Tin and gold does not shrink or change form as does 
much of the amalgam in use, and it is accordingly a better protec- 
tion to the cavity-walls. If an operator becomes expert in its 
manipulation he will find a large range of usefulness for it in his 
practice, and it will not prove a disappointment. 

In using tin foil for filling teeth, the same general plan of 
manipulation is indicated as that just outlined for tin and gold. 



MAinPULATION OF AMALGAM. 235 

CHAPTER XII. 

MANIPULATION OF AMALGAM. 

It may be considered scarcely practicable to lay down any in- 
variable rule in regard to the percentage of mercury which must be 
mixed with an alloy to gain the best results in an amalgam. The 
vast number of alloys on the market and the variable requirements 
in the different makes render the question of percentage a difficult 
one. The most that can be done is to suggest in a general way the 
manner of mixing the alloy with the mercury, and indicate as ac- 
curately as may be the proper consistence or plasticity of the mass 
to secure the best results. While it is a mooted question as to 
whether or not it may be injurious to an amalgam to so mix it that 
an excess of mercury is added and subsequently wrung out before 
inserting the filling, it will be found that practically under present 
conditions the most uniform product may be obtained in that way. 
If manufacturers would put up their alloy in small capsules with an 
accompanying capsule of mercury accurately weighed out in the 
per cent, that has been demonstrated by experiment to be the best 
for that particular alloy, it might be practicable to so mix amalgam 
in office work that there need never be any free mercury present; 
but the fact that this experiment has been tried by at least one 
manu"'^acturer and failed to receive the support of the profession 
would seem to indicate that the profession was not willing to yield 
this much homage to the material. ISTeither can it be expected 
that practitioners generally will ever be persuaded to take the 
trouble to weigh out the exact proportions for each filling in the 
daily routine of practice, even where it is possible to ascertain the 
proper proportion for the alloy they are using. It would be the 
ideal method if this could be done, but it may well seem fruitless to 
advocate any method of practice which the profession manifestly 
will not follow. 

In onr teaching we must aim to accomplish the greatest good 
to the greatest number, and with the varying alloys on the market 
the surest way to do this is to give the technical procedure neces- 



236 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

sary to the best preparation of the allov for filling. With most of 
the alloys at present in use by the profession the amalgamation 
of the mass does not seem to take place so readily as those in com- 
mon use a dozen years ago, and the mass therefore requires more 
extended mixing in order to secure a perfect incorporation of the 
mercury with the fillings. To do this it is advisable to use a pestle 
and mortar at least in the early part of the mixing. This mortar 
should be of appreciable size, and the inner surface of the bowl 
should be roughened. The small smooth glass mortars sometimes 
offered for sale for mixing amalgam are not at all suited to the 
purpose, there being insufficient area for trituration and no re- 
sistance to the gliding of the mass along the inner surfaces in front 
of the pestle. A roughened surface results in the ingredients be- 
ing caught between the pestle and the mortar so that they receive 
the proper amount of grinding. 

Sufficient mercury for the case in hand should be placed in the 
mortar, and filings added little by little as the grinding proceeds, 
until the mass reaches a consistence which would seem to indicate 
that if more filings were added it would interfere with the plastic- 
ity of the product and render it granular. At this point it is well 
to transfer the mass to the palm of the hand and knead it quite 
vigorously with the ball of the finger of the other hand. This 
kneading will usually result in increasing the plasticity of the mass, 
and if it is found that too much mercury is apparent some more 
filings should be added and the kneading continued. The mass 
should be mixed just to the point where there seems to be a com- 
plete incorporation of the filings with the mercury and where pres- 
sure of the mass, such as wringing vigorously in chamois or strong 
linen with the fingers, will result in a minute quantity of mercury 
being expressed from it. In view of a possible disarrangement 
of the formula of the alloy by carrying away more of one metal 
than another in the expressed mercury, it is always well to have 
the mass of such consistence that it is possible to wring out only a 
very small amount. When the mass is taken from the linen it 
should break apart easily with little apparent plasticity to it, and 
if the amalgam is of the quick-setting variety it should be kept 



MANIPULATION OF AMALGAM. 237 

under constant movement till the last piece is condensed in the 
cavity. That is, when part of it has been placed in the cavity pre- 
paratory to condensing it the portion remaining on the operating 
table should be kneaded by the assistant till it is required, and if 
the operator has no assistant he should manage in some way with 
the fingers of his left hand to keep the mass in motion. If he 
finds this impracticable he would better select a slower-setting 
alloy. 

Method of Packing Amalgam. 

The pluggers used for this purpose should be flat-faced instead 
of rounded, and should be as large in area as can conveniently be 
employed in the given cavity. The idea should always be to carry 
the mass in front of the plugger directly against the cavity-wall, 
instead of having it squeeze out alongside the instrument. Amal- 
gam should not be treated as if it were intrinsically a plastic ma- 
terial and could be patted to position with little force. Amalgam 
to gain the best results must be condensed by heroic pressure. If 
too small an instrument is used, a sufficient pressure for proper 
condensation will result in the plugger piercing the mass and driv- 
ing the material to either side of it. The aim should be to keep 
the mass gathered before the instrument so that it is carried only in 
the direction toward which the force is exerted, and to accomplish 
this a broad flat-faced plugger is necessary, unless the area of the 
cavity is so small that the amalgam is forced against the surround- 
ing walls. If a filling is to be made which is not more or less 
porous, the ingredients of the amalgam must receive vigorous com- 
pression. Realizing this, some operators recommend mallet force 
to condense amalgam, but it would seem to be immaterial which 
way the force is applied, whether by mallet or hand pressure, so 
long as the compression is sufficiently forceful. 

Recognizing the character of amalgam, it will readily be ap- 
preciated that to secure the best results in its insertion it is neces- 
sary to have a cavity with surrounding walls instead of one with 
an open aspect and one wall missing, as in a proximo-occlusal cavity 
in a molar. All cavities, therefore, involving the proximo-occlusal 
surfaces should be reinforced by a matrix to gain the best results in 



238 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

condensation. In cases of very extensive restoration where the 
tooth-tissue has been badly broken down, a matrix of thin German 
silver should be made for the case by wrapping a strip of the ma- 
terial around the tooth and tacking the ends together with solder. 
When this is slipped over the tooth it can be burnished to the 
proper form, and after the insertion of the filling the matrix may 
be allowed to remain on the tooth till the following day as a sup- 
port to the amalgam during the process of crystallization. At the 
next visit of the patient the matrix may be cut and removed and 
the filling polished. 

The manner of inserting amalgam is to take a small piece in the 
pliers and carry it to place in the cavity, condensing it thoroughly 
before another piece is added. As the filling is thus being built 
up piece by piece, if the compression results in bringing surplus 
mercury to the surface the soft mass thus resulting should be 
scraped from the filling and the next piece of amalgam added to 
the harder portion beneath it. An amalgam filling cannot have 
a satisfactory surface with an excess of mercury present. Even 
if it did not interfere with the integrity of the mass, there would 
still remain a physical reason why a softened surface is contra- 
indicated, l^o operator can be certain that he has secured uni- 
form adaptation to cavity-walls in the attempt to condense a soft 
mass of amalgam. This material under those conditions acts rela- 
tively like a mass of jelly, so that if the operator forces it against 
one margin it is immediately drawn away from another. The only 
possible way to be assured of adaptation to all of the outlines of a 
cavity in the effort to insert soft amalgam would be to have a plug- 
ger point as broad as the area of the cavity, and bring force over 
the entire surface of the filling at the same time. This, of course, 
is seldom feasible, and it will accordingly be apparent that to get 
good results with amalgam and produce a filling which does not 
leak at some point it must be used without an excess of mercury. 

When the filling is built to the requisite fullness it should at 
once be trimmed to form before it is allowed to become hard. The 
occlusal surface may be smoothed by taking a pellet of tightly 
rolled cotton in the pliers and gently wiping it across the surface, 



MANIPULATION OF CEMENTS. 239 

always in the direction of the margins. Any surplus on the proxi- 
mal surface in the interproximal space must be carefully removed 
at this sitting with thin amalgam trimmers. If small particles of 
the material are allowed to extend over the cavity-margins at this 
point till crystallization has taken place it will be found very diffi- 
cult to remove them, and if they are not removed and the filling 
made smooth and even with the surface of the enamel the gum in 
the interproximal space will invariably present an abnormal con- 
dition on account of the irritation. It is necessary to look as care- 
fully to the finish of an amalgam filling at this point as to a gold 
filling, and the trimming to form should invariably be done while 
the amalgam is still semi-plastic. Close attention should also be 
given to the occlusion, so that an opposing cusp may not injure the 
filling by too great impact before it is hard. 

When the filling is thus properly formed the case may be dis- 
missed till another sitting, at which time it should be polished with 
the same care and in the same manner as a gold filling. Amalgam 
will take a most beautiful finish, and if inserted with painstaking 
care along the lines indicated, and polished at a subsequent sitting, 
the results in amalgam work will prove more beneficial and more 
uniformly satisfactory than we ordinarily see in the mouths of our 
patients. 



CHAPTEK XIII. 

MANIPTLATION UF CEMENTS. 

In the preparation of cement for filling teeth the plan of mixing 
is somewhat important. A quantity of powder sufficient for the 
case in hand should be placed upon the mixing slab, and a short 
distance from this the requisite amount of liquid. The means 
used to dip the liquid from the bottle should be such as not to 
contaminate the remaining contents of the bottle. The liquid of 
cement to give the most serviceable working quality should be of 
a consistence bordering closely on crystallization. In fact, a liquid 
which presents no tendency to crystallization and which remains 



240 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

permanently fluid under all circumstances cannot be considered 
the safest kind of liquid for ordinary use in the mouth. This 
tendency in most of the reliable fluids renders it necessary to 
handle them with great care, to avoid as largely as possible the 
formation of crystals. Crystals are readily formed if small quan- 
tities of the liquid are left exposed to the air, and thus we find 
about the mouths of the bottles more or less of a crystallized mass, 
on account of leaving a surplus of the material clinging to the 
cork and smeared over the rim of the bottle. Small particles from 
this crystallized mass dropping into the bottle from time to time 
tend to start other centers of crystallization in the fluid, and the 
entire contents of the bottle may thus be contaminated. In view 
of this it is always desirable to keep the mouth of the bottle as free 
from the liquid as possible, and consequently the practice of pour- 
ing the liquid from the bottle to the slab is contraindicated. The 
liquid should be carefully dipped out and dropped on the slab by 
some instrument which is not in any way acted on by the liquid. 
The ordinary steel spatulas are more or less affected by the acid in 
the liquid, and should not be used either for dipping out the liquid 
or mixing the cement. Dr. W. V-B. Ames suggests for this pur- 
pose a spatula made of German silver, which is sufficiently rigid for 
a thorough trituration of the cement and which is not affected by 
the liquid. It need not be intimated that the spatula should never 
be placed in the liquid to dip an additional amount from the bottle 
after it has been used to commence the mixing. If more liquid is 
required, it should be dipped with a glass rod or some non-corrosive 
instrument. 

In mixing the cement the powder should be added to the liquid 
little by little, the mass meanwhile being thoroughly stirred and 
rubbed with the spatula. Most operators fail to mix their cement 
with sufficient vigor to obtain a perfect incorporation of the powder 
with the liquid. The best results are gained by a very vigorous 
rubbing over a considerable area of the slab, — the powder being 
added till the mass is almost as stiff as freshly prepared putty. If 
it is to be used for the temporary sealing of medicaments in a 
cavity or for any purpose where pressure cannot be used in its in- 



MANIPULATION OF CEMENTS. 241 

sertion, it may be left more plastic so as to flow with little resist- 
ance, but if to be used for fillings it should be made reasonably stiff 
and then forced into place with considerable pressure. 

A convenient means of carrying the mass from the spatula to 
the cavity is to first gather the cement into a ball on the end of 
the spatula, and then, having some cotton rolled into a tight, com- 
pact pellet, grasp this firmly with the pliers and use it as a means 
of scraping the cement from the spatula to the cavity. The cot- 
ton must be rolled tight to prevent the cement from clinging to it. 
Some varieties of cements are more adhesive to cotton than others, 
but with most of them if they are mixed sufiiciently stiff to yield 
the best results in fillings the tight cotton roll may be used very ad- 
vantageously. When the cement has been pressed to place in the 
cavity with the cotton and the excess wiped away, still further 
compression may be made with a broad, smooth, flat-faced plugger 
just as the mass begins to crystallize, but after crystallization has 
once definitely set in the filling should not be disturbed by manipu- 
lation till it has become hard. The filling should be dressed to the 
proper form while it is still soft by the use of thin instruments of 
a form indicated by the requirements of the case, the trimming 
always being done toward the margins. 

In using cement for children's teeth in those incipient cavities 
in the occlusal surfaces of bicuspids and molars, a most effective 
means of forcing the cement to place and keeping it dry for a few 
minutes after its insertion is to carry the material to the cavity in 
the ordinary way and press it inio position with the cotton pellet, 
leaving an excess heaped up over the vicinity of the cavity. On 
this excess the ball of the operator's finger should be placed, cover- 
ing 'the entire occlusal surface of the tooth and forcibly com- 
pressing the cement into position till the surplus is squeezed out 
over the marginal ridges of the occlusal surface. The finger 
should be most vigorously forced against the tooth and held there 
with considerable compression till the cement has begun to crystal- 
lize, after which the surface may be smoothed with an instrument. 



16 



242 PKINCIPLES AND PBACTICE OF FILLING TEETH. 

CHAPTEE XIV. 

MANIPULATION OF GUTTA-PEKCHA. 

The great desideratum in the use of gutta-perclia is to so regu- 
late tlie heat in softening it that the mass will be made sufficiently 
pliable to be readily inserted in the cavity without in the slightest 
degree overheating the material. If gutta-percha is brought into 
contact with the flame it is almost instantly charred and ruined, 
and should never be introduced into a cavity. The most effective 
means of heating it is on a warm porcelain slab placed some dis- 
tance from the flame so that the heat is gradual and steady, but 
if the operator cannot take the time for this he may get satisfactory 
results by heating it over a flame, provided he exercises sufficient 
caution. The pieces of gutta-percha may be grasped in the pliers 
and held so far above the flame that the heat is not intense enough 
to injure the mass, and when sufficiently warmed they may be car- 
ried directly to the cavity and compressed to place. If the ordi- 
nary pink gutta-percha base-plate is used — and this makes a more 
permanent filling than any of the white preparations — there is 
another reason why the heating should be carefully watched. 
This material requires greater heat to render it soft than most 
other forms, and it is therefore inclined to cause pain when ap- 
plied to a tooth with a living pulp, and the slightest degree of 
overheating adds seriously to the discomfort. The idea with any 
gutta-percha is to warm with a low degree of heat continued for 
some time, the reason being that the conductive properties of the 
material are poor and it requires time to make the mass uniformly 
soft. A rapid heating at high temperature simply sears the sur- 
face without softening the entire piece. 

For temporary work such as sealing medicaments in teeth the 
softer forms of gutta-percha known as the temporary stoppings are 
preferable to the base-plate. They are softened with much less 
heat, are readily molded to cavity-walls, making perfect sealing 
agents, and are more easily removed. In using them care must 
be exercised not to overheat, because of ,the disagreeable stickiness 



MAKING INLAY FILLINGS. 243 

which too much heat imparts to them. If gently heated thej may 
be made soft at a temperature which will permit of the mass being 
kneaded between the thumb and finger like putty. 

In finishing a gutta-percha filling the surplus may be trimmed 
away with a heated instrument, dressing always toward the mar- 
gm. If there seems a tendency for the gutta-percha to curl away 
from cavity-margins the instrument should be made just warm 
enough to slightly soften the mass, and then the broad side of it 
should be placed forcibly against the surface of the filling and held 
there with considerable compression till it becomes cool. The 
gutta-percha will then remain stationary. 



CHAPTEK XV. 

MAKING INLAY FILLINGS. 

The two kinds of inlays most in use are the porcelain inlays for 
exposed positions in the anterior teeth, and gold inlays in bicuspids 
and molars where the stress of mastication is an important con- 
sideration. An inlay is made by first fitting a thin metal matrix 
to the cavity, and then flowing into this the inlay material to the 
required contour and cementing it into position in the tooth. 

Porcelain Inlays. 
The demand for porcelain inlays sprang from the indiscriminate 
and inartistic display of gold in the anterior part of the mouth, 
whereby the esthetic sense of the people has been too frequently 
offended. If the profession had more carefully studied the possi- 
bilities of platinum and gold for harmonizing shades on exposed 
surfaces, there never would have developed the reflection upon 
dental art that has been justly urged against it, but it still remains 
true that there are certain cavities in which a well-made porcelain 
inlay is more artistic in appearance than it is possible to attain with 
any metal filling. It is also true that inlay work is less exhausting 
to the patient than extensive filling-building, and these two con- 
siderations should induce every operator to so perfect himself in 



244 PEINCIPLES AND PKACTICE OF FILLING TEETH. 

inlay work that lie is enabled to give his patients the benefit of the 
highest class of skill in those cases where inlays are indicated. 

The chief indications for inlays in the anterior teeth relate to 
cavities with an open aspect presented to the labial. These may 
occur occasionally in the labio-proximal region, giving a broad 
labial exposure with a strong lingual wall still standing, but the 
most frequent demand for inlays is in those cavities occurring 
in the labial surface near the gum. The preparation of the cavity 
for an inlay involves the thorough opening up of the cavity so 
that no overhanging walls are left. The orifice must manifestly 
be broader than the interior, else the inlay if accurately fitted will 
not pass to place, but on the other hand the cavity must not be 
Fig. 99. left too shallow or too much saucer-shaped on account of 
the difficulty of maintaining an inlay in position in a 
cavity so formed. The marginal outline should be made 
symmetrical and artistic, but the enamel for a porcelain 
inlay should not be so extensively beveled as to necessi- 
tate a thin edge to the porcelain. If possible the sur- 
rounding walls of the cavity should flare out very gently as they 
approach the enamel-surface, thu:s readily admitting the inlay to 
place, and protecting the enamel without creating an attenuated 
and friable edge to the inlay. (Fig. 99.) 

If decay has so extended into the tooth at any point as to make 
a perceptible undercut, but has left the enamel so well supported 
that it is undesirable to open the orifice of the cavity sufficiently 
to do away with the undercut, the deeper portions of the cavity 
may be filled with cement to produce such a form that the matrix 
can be withdrawn from the cavity without changing shape. 

The entire plan of cavity formation for inlays — particularly as 
it relates to the making of angles in the interior of the cavity — ^is 
different from that for the insertion of fillings. For inlays there 
should be no sharp angles anywhere, and the instruments used 
for shaping the cavities should accordingly be different in form 
from those for cutting cavities for fillings. If excavators are used 
they should be spoon-shaped instead of the usual hatchets or hoes, 
and where burs are employed they should be round. The cavities 



MAKING INLAY FILLINGS. 245 

should be formed on curves, though in complex cavities the gen- 
eral plan of step anchorage should be followed as far as possible. 
In other words, the inlay should have as broad a seating capacity 
as is practicable without sharp angles between the walls. 

In large cavities in bicuspids and molars much of the cutting 
may be done with stones, chisels, and disks, and the fact that it is 
seldom necessary to apply the rubber dam for this work makes 
it less irksome to the patient. 

Fitting the Matrix. 

Whether the matrix is to be of platinum or gold the same gen- 
eral plan of procedure is applicable. If platinum is used it should 
be from 1-1500 to 1-1000 of an inch in thickness. For gold inlays 
the ordinary No. 60 beaten foil mil be found convenient for the 
matrix. 

There are two general methods of forming the matrix — one to 
take an impression of the ca\dty, make from this a model, and 
swage the matrix to the model ; the other, to fit the matrix directly 
to the cavity in the tooth. Each method claims its adherents 
among inlay-makers and each has its advantages in certain cases, 
but for general use in the cavities where inlays are most indicated 
it would seem an unnecessary expenditure of time and energy to 
invariably take an impression of the cavity and make a model. 
The argument is frequently urged in support of this method that a 
burnished matrix can never be made to fit so perfectly as a swaged 
matrix, and that therefore a model should be made for swaging 
purposes. This argument can readily be met by the statement 
that the most approved methods of fitting a matrix to the cavity 
in the mouth involves a system of swaging instead of burnishing, 
and that we are thereby enabled to bring the matrix into as close 
relationship to the cavity without warping as would be possible 
on a model. It is true that the early efforts at burnishing the 
matrix to the cavity %vith a metal burnisher were faulty in view 
of the tendency to warp the matrix, but this is no longer necessary. 

Talcing an impression of the cavity. For those cases where the 
operator decides that he can do better work on a model than in 



246 PKINCIPLES AND PKACTICE OF PILLING- TEETH. 

the moutiL, an impression of the cavity may be taken in the follow- 
ing way : After the cavity is properly prepared it should be dried 
and freely dusted with soapstone or Talcum powder, rubbing the 
interior well with the powder by means of a pellet of cotton to 
prevent adhesion of the impression material to the walls. Some 
quick-setting cement should then be mixed and a mass of it rolled 
and kneaded in the fingers, at the same time incorporating some 
of the Talcum powder into the surface of the cement. This should 
then be forced into the cavity and a sufficient surplus used to give 
a perfect outline of the enamel margins. When hard it should be 
gently lifted from the cavity and properly trimmed, leaving in all 
cases the marginal outlines of the cavity well marked. A model 
from this impression may be made with copper amalgam, the oxy- 
phosphate of copper, or the ordinary oxyphosphate of zinc — ^the 
same precautions as before being necessary to prevent adhesion. 
Into the model so made the matrix may be swaged by a flexible 
water^bag made for this purpose, or by forcing it to place with a 
miass of unvulcanized rubber. 

There is one advantage of working from a model: The inlay 
during the process of construction may be carried to the model 
after each baking, and if there has been any change of form in 
the matrix due to shrinkage of the porcelain in fusing, it is over- 
come by again swaging the margins of the matrix to the model. 

Adapting a matrix to the cavity in the tooth. A piece of the 
matrix material, whether of platinum or gold, considerably larger 
than the area of the cavity should be annealed and placed over 
the orifice of the cavity. Care should be exercised in placing it so 
that when forced to the bottom of the cavity there shall be a 
surplus extending beyond the entire marginal outline of the 
cavity. Unless attention is given to this the matrix is liable to be 
drawn more to one side than the other in the early stages of the 
swaging, leaving some one part of the cavity outline uncovered 
by the matrix. Eor carrying the matrix to position in the cavity 
a pellet of wet cotton sufficiently large to cover the bottom of the 
cavity should be grasped in strong-pointed pliers and very gently 
forced in the direction of the deeper portions of the cavity. If 



MAKING INLAY FILLINGS. 247 

tills is done carefully it will usually be found possible to carry 
the matrix to the depth of the cavity without serious tearing of 
the metal. When this first pellet has been forced to the bottom, 
another hard-rolled pellet should be used to gently wipe the curled- 
up margins of the matrix back toward the cavity margins to get 
them out of the way, but under no circumstances should there be 
any attempt made to fit the matrix accurately to the margins at 
this stage. The object is to secure a perfect adaptation of the 
matrix to the bottom of the cavity first. To this end wet cotton 
should be packed in, pellet after pellet, till the soggy mass is tightly 
wedged against the walls of the cavity, each pellet being driven 
forcibly home with pluggers or burnishers having large ends. If 
sufiScient cotton is kept in the cavity there is no tendency of the 
matrix to spring away from one point while it is being forced 
against another. In fact it becomes a process of swaging instead 
of burnishing, and in this connection it may be stated that it is 
seldom necessary or advisable to allow the burnisher to come in 
contact with the matrix. All the force should be exerted upon 
the cotton and through that to the matrix. "When the cavity is 
nearly full of the cotton and the entire mass tightly packed against 
the cavity walls an accurate fitting of the. margins of the matrix 
may usually be obtained to better advantage with a layer of un- 
vulcanized rubber than with anything else. This should be placed 
over the cotton and with a broad burnisher the rubber forcibly 
compressed over the entire marginal outline of the cavity, carrying 
the matrix into the closest possible adaptation to the enamel mar- 
gin throughout, but having the same care as before about letting 
the burnisher touch the matrix. It requires but very little rubbing 
of the metal burnisher against the matrix to harden it and make 
it curl away from the margin. 

When the fitting has been as accurate as possible, the rubber 
should be removed and the cotton picked out piece by piece. A 
close scrutiny can then be given the matrix to see if the adapta- 
tion is good and the cavity margins sharply outlined. If there 
seems any defect or failure of adaptation the process of swaging 
should be repeated before the matrix is removed from the cavity, 



248 PKINCIPLES AND PEACTICE OF FILLING TEETH. 

the object being to make tbe one insertion of the matrix answer 
the purpose instead of repeatedly removing it and inserting it. 
The less handling the matrix receives outside the cavity the safer 
it is, and frequently the attempt to place it back in the cavity 
after it has been once removed injures its form and prevents as 
perfect a refitting as it was capable of receiving in the first in- 
stance. 

When assurance is had that the matrix is satisfactory in fit it 
should be very gently teased out of the cavity by placing a sharp 
exploring instrument under the free margin which extends beyond 
the cavity, and at some point opposite a place in the cavity where 
on account of its form the matrix would naturally be expected to 
yield readily. A little adroitness and delicacy of manipulation 
will usually result in loosening the matrix and lifting it from the 
cavity without marring it or changing its form. 

In cases where contour work is to be done the matrix should be 

made to lap the cavity-margins sufficiently to give an outline of 

the surrounding surfaces as a guide in building the inlay to the 

proper contour. 

Porcelain Bodies. 

The question of the most suitable body for use in porcelain in- 
lays has been quite extensively discussed by the profession, and 
there seems to be much diversity of opinion as to whether a low- 
fusing or a high-fusing body is indicated. The question cannot 
as yet be considered as settled, nor will it be until we have had a 
more extended experience with the various grades of porcelain in 
the mouth. Practical utility is the supreme test in all these things, 
and it will probably take years of observation to arrive at definite 
conclusions, but from what we have already seen of the behavior 
of porcelain it would seem that the chief reliance should be placed 
upon the high-fusing bodies. By high-fusing body is meant a 
porcelain which fuses at a temperature above the melting-point 
of pure gold, thus dem^anding platinum as a matrix, while a low- 
fusing body is one which may be fused upon a gold matrix. The 
chief contention made by the advocates of the latter is that a gold 
matrix may be more readily fitted to a cavity than one of platinum. 



MAKING INLAY FILLINGS. 249 

and therefore a low-fusing body is preferable, but with the careful 
preparation now given to the manufacture of platinum for this 
purpose there is really not sufficient difference between the two 
materials to furnish a tangible argument. 

In the past it has been found that the color of the low-fusing 
bodies has not proved sufficiently stable to withstand the fluids of 
the mouth, nor has it been so easy to obtain the exact shade in 
fusing. The character of the coloring material in these bodies is 
such that the least overheating beyond the precise point of fusing 
is liable to burn out the color and leave a bleached effect. For 
these reasons it would seem only common justice to our patients 
to confine ourselves to high-fusing porcelain, at least until it shall 
ha^■e been demonstrated that the more recent and more carefully 
prepared low-fusing products prove their reliability by extended 
usage in the mouth. 

Before an operator attempts porcelain inlay work he should 
make himself familiar with the management of high-fusing bodies 
both in relation to the method of baking and the control of shades, 
and this can only be attained by actual experimentation with the 
material itself. 

Matching Shades. 

There can be no set rule given for the matching of shades in the 
wide variations encountered in the mouth, though any dentist of 
fine artistic sense can obtain very satisfactory results by a close 
study of the problem with the aid of the shade guides now fur- 
nished for this purpose by the porcelain makers. Dr. W. T. 
Reeves, of Chicago, has given some very useful suggestions along 
this line which it will be well for the inlay worker to study. The 
basis of his method of shading lies in the fact that the human 
enamel is more or less transparent and that therefore the shades 
of the teeth are regulated by the underlying tissue. In view of 
this Dr. Reeves suggests that the basal shades of any particular 
tooth to be matched should be baked into the foundation body of 
the inlay, and a nearly transparent enamel body of lower fusing- 
point than the foundation baked over this to complete the inlay. 



250 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

There are many little knacks of blending colors to match differ- 
ent shades which the observant operator will soon acquire, and the 
more this fascinating subject is studied the more its possibilities 
open up. There are certain positions in the mouth which, on 
account of the manner in which the light strikes them, render it 
almost impossible to simulate true enamel, and yet the effect with 
a well-made porcelain inlay is never so conspicuous as with a 
metallic filling. 

It will be found that the varying shades of a tooth from the 
gum margin to the incisal edge must be distinctly recognized to 
get the best results, and there is one practical point in this connec- 
tion worth recording. Where an inlay is to be made for a labial 
cavity in the gingival third of the tooth the shade selected should 
be somewhat darker than would seem suitable when matching it 
with the shade guide. This is in accordance with the fact that the 
teeth usually deepen in color as they approach the gum, and it is 
particularly applicable to cuspids for another reason. When 
standing immediately in front of a patient the labial surface of a 
cuspid is so presented to the observer that the light readily passes 
through the inlay so as to make it appear translucent and lighter 
in color than it really is. It will be found that there is a great 
difference in the appearance of one of these convex inlays in a 
cuspid when viewed from different positions. An inlay which 
may seem perfect in match when the operator is standing a little 
to one side so as to look directly against the labial convexity of 
the tooth will appear much too light when he steps around to the 
other side of the patient and views it diagonally across the labial 
surface. The shade should be so arranged as to give the best 
results at conversational distance from the patient in the varying 
lights and shadows which play about the mouth, and this can 
usually be done by selecting the darker shades for this region 
of the tooth. 

Baking the Porcelain. 

The time required for fusing porcelain depends on the kind of 
furnace and the grade of porcelain, and instructions in this regard 



MAKING INLAY FILLINGS. 251 

are given by the manufacturers, but for the mixing and manipula- 
tion of the material a few practical points rasij be mentioned. 
Absolute cleanliness is the cardinal requisite in handling porcelain. 
The matrix should be perfectly clean and free from saliva or 
blood. The porcelain slab, the spatulas, and the water used for 
mixing should also be clean. A sufficient amount of foundation 
body for the case in hand shouU be thoroughly mixed with water 
and the floor of the matrix covered with it. In case there has been 
a break in the matrix in the deeper portions of the cavity the porce- 
lain will usually flow over this without detriment. The matrix 
may be handled by grasping the free margin most distant from 
the cavity with pliers, and when held in this manner the porcelain 
should be settled into the matrix in such a way that the particles 
of porcelain are brought into the closest possible relationship with 
each other, to prevent as nearly as may be an undue shrinking of 
the porcelain in fusing. This can be done by rubbing a rough- 
handled instrument of some kind across the pliers which hold the 
matrix, thus jarring the matrix and settling the particles of porce- 
lain to the bottom and bringing the water to the top. The surplus 
water may be absorbed with clean blotting paper and the jarring 
continued till the porcelain is thoroughly compact. It should 
then be dried further with heat and passed to the furnace and 
fused, the first baking usually being carried only to a biscuit and 
not to a complete fusing. When the foundation is thus laid the 
inlay is built to full form with the enamel body, which latter 
should be perfectly fused to give it a uniform transparent gloss. 
The number of bakings varies with different cases — small inlays 
sometimes being completed with two bakings, while the more 
complicated cases may require four or five to gain the best results. 
When the inlay is baked the platinum matrix should be peeled 
away, leaving the porcelain ready for setting. If the form of the 
cavity is such that the retention of the inlay is in doubt, the former 
may be undercut with a bur or excavator and the cavity side of the 
inlay grooved with a thin disk. In any event the glazed surface 
of the porcelain next the cavity should be slightly ground with a 
stone, so as to present a better surface for adhesion. In setting the 



252 PKINCIPLES AND PRACTICE OF FILLING TEETH. 

inlay the cavity should be dry and the cement carefully mixed to 
such a consistence that it will require some force to squeeze it 
out from under the inlay, but it should not be so stiff that the 
inlay cannot be driven perfectly in place. In forcing the inlay 
a wooden point may be used, and considerable pressure should be 
maintained on the inlay for several minutes till the cement begins 
to crystallize, after which the surplus may be trimmed away and 
the margins wiped clean with cotton. 

It will usually be found that a porcelain inlay is not quite so 
satisfactory in appearance after setting with the cements we now 
have, as when simply placed in the cavity preparatory to setting, 
nor can we hope to overcome this limitation till we get a cement 
which is transparent. 

Gold Inlays. 

There is really a wide range of usefulness for this kind of inlay 
in those cases — already indicated — ^where the extent of the decay 
has been so great that a gold filling is contraindicated on account 
of the nervous tax on the patient. The entire operation is much 
less exhausting than filling, and while in view of our limited ex- 
perience in their use the results can never be predicted with so 
much certainty as with a well-inserted foil filling, yet if the cases 
are selected with discriminating judgment and the operation per- 
formed with painstaking care the practice is justifiable in many 
instances. 

The preparation of the cavity must be along the same lines as 
for porcelain inlays, except that the question of anchorage is more 
important, and in proximo-occlusal cavities the occlusal step 
method should be followed wherever available. A gold inlay 
locked into a step at right angles with the proximal portion of the 
cavity is peculiarly calculated to remain secure against dislodg- 
ment. Another distinction in the preparation of cavities for gold 
inlays relates to the treatment of enamel-margins. "With gold in- 
lay work the margins should be very freely beveled and the edges 
of the inlay carried well over them. This is one of the most ser- 
viceable features of gold inlays, that all thin or frail enamel walla 



MAKING INLAY FILLINGS. 253 

may be dressed down and the inlay so built over them as to per- 
fectly protect them. In contradistinction to porcelain inlays, the 
edges of gold inlays are very strong and capable of protecting 
weak enamel. This overlapping of the cavity-margin by the in- 
lay would also seem to largely do away with the tendency for the 
cement to dissolve out to any appreciable distance under the inlay. 

The matrix for gold inlays may be made from pure gold, a 
convenient thickness for this purpose being found in one of the 
heavier forms of gold used for finishing fillings, such as the No. 60. 

After the matrix is fitted it should be invested in investment 
plaster, and when this is hard any torn places in the matrix may 
be remedied by burnishing over them some crystal gold used for 
filling teeth, into which the solder will soak and effectually repair 
the breach. The same care in inlay work should be exercised with 
relation to contour and contact that has already been advocated 
for an ordinary filling, and to this end the gold inlay should be 
built up with the blow-pipe by the same operator who fits the 
matrix, so that he may have in his mind the relation of the proxi- 
mating tooth and accordingly be able to build out the inlay to the 
proper contour at the contact point. A little practice in this work 
will enable the operator to so form his inlays that very little grind- 
ing is necessary, though it should usually be his aim to make the 
inlay overfull at the contact point rather than not full enough. 
It is more convenient to grind away a slight surplus than to add 
more gold when the inlay is being fitted previous to cementing. 
A high-grade solder — about 20-carat — ^should be used to fill the 
matrix. The piece should be gently heated up to prevent the for- 
mation of steam under the matrix and its consequent displacement. 

The aim should be to first carefully cover the entire surface of 
the matrix with a thin layer of solder, and then the subsequent 
pieces may be added without danger of melting the matrix. As 
the contour is being given the inlay, the pieces of solder should 
be merely sweated on the surface and in this way the inlay may 
be contoured out to any desired form without fusing the entire 
mass and having it flow out of position. 

In fitting the inlay to place before cementing it, attention should 



254 PKINCIPLES AND PRACTICE OF FILLING TEETH. 

be given to the occlusion of the opposing tooth, and the inlay so 
ground that it will not require further attention in this respect 
when cemented. In driving the inlav to position into the cement 
a plugger and mallet may be used, and the inlay held firm till 
crystallization has commenced in the cement. After this has 
taken place if there is any unevenness along the junction of the 
inlay and enamel it may be ground smooth and even, and then 
polished with a sand-paper disk. A well-fitted gold inlay so in- 
serted may often be mistaken for a beautiful gold filling, and this 
may be said to involve the highest excellence in gold inlays. 



CHAPTEK XVI. 

PULP-CAPPING. 



When decay has penetrated a tooth sufficiently to reach the 
pulp, the problem arises as to whether an attempt shall be made 
to save the pulp by capping or whether it shall be destroyed and the 
canal filled. The question is one which calls for discriminating 
judgment on the part of the operator and a careful study of the pe- 
culiar manifestations presented in the individual case. 'No set rule 
can be formulated as a guide under all conditions, but the most 
prominent indications for or against pulp-capping may be pointed 
out in the way of suggestion to the observant operator. 

The chief considerations relate to the age of the patient, the ex- 
tent of exposure, the location in the mouth of the affected tooth, 
and the duration and degree of the pain caused by the exposure. 
In young patients the prospect of saving a pulp alive is greater 
than in aged patients, and the necessity is also more urgent. A pulp 
is never through with its active functional duty till the tooth is 
completely calcified to the very apex of the root, and this does not 
take place till after the eruption of the crown through the gum. 
In fact, teeth may erupt and take on the carious process to the ex- 
tent of pulp-exposure before the apex of the root is formed, and 
if there is death of the pulp at this stage the apex is left unformed. 
It becomes important, then, in all cases of pulp-exposure in young 



PULP-CAPPING. 255 

patients to attempt to save the pulp till the process of calcification 
is complete, and while teeth may vary in different mouths in regard 
to the age of complete calcification, it may be said in a general way 
to be about six years after they begin to erupt. The fact that 
pulps may more successfully be saved during youth is another 
argument in favor of making the attempt, the reason for this be- 
ing that the apical openings in the roots are larger, which gives 
greater play for the engorgement of the vessels of the pulp without 
injury. As age advances the apical openings become smaller, and 
a very slight irritation of the pulp may cause its death. 

The extent of the exposure is also an important factor. If 
the pulp is only slightly exposed and has not been injured in any 
way, or if it has been accidentally uncovered by an excavator, the 
chances of saving it are greater than where the exposure is large 
and the pulp thereby subjected to all the dangers of infection. 
One of the chief elements of success in pulp-capping relates to the 
avoidance of pressure on the pulp, and in large exposures this is 
more difficult. 

The question of location in the mouth refers to teeth that are 
exposed to view in contradistinction to teeth so situated that they 
are never seen in ordinary conversation,— the difference being that 
with the former a greater effort should be made to save the pulp 
than with the latter. The reason for this is that on death of the 
pulp there is usually a tendency for the tooth to become more or 
less discolored and lose its normal translucency — sometimes to the 
extent of being unsightly and conspicuous. The fact that by 
proper management from the time the pulp is destroyed to the 
final filling of the cavity any serious discoloration may ordinarily 
be avoided does not alter the general proposition that the most 
conservative practice involves the saving of pulps in such teeth if 
possible. An operator is never able to predict with certainty that 
a pulpless tooth will permanently retain its color even under the 
best treatment, and it may therefore be considered a legitimate 
procedure to make the attempt at pulp-preservation in many of 
these cases even where the chances are against it. There is a wide 
variation in the tenacity of life exhibited in different pulps, and 



256 PEINCIPLES AND PEACTICE OF FILLING TEETH. 

if there is a reasonable promise that the pulp may be saved in- 
one of the anterior teeth it should be given the benefit of the 
doubt and treated accordingly. But the operator should invari- 
ably protect his reputation by a straightforward statement of the 
facts in the case to the patient, and a plain disavowal in advance 
of any responsibility in the event of the pulp dying under the 
capping. If patients are at all intelligent they will appreciate 
an operator's efforts on their behalf, and will not hold him blame- 
worthy if the issue turns out amiss.. With patients who are not 
reasonably disposed the operator would better take no chances, but 
proceed to destroy all pulps where there is doubt of their preserva- 
tion. Patients of this type are not entitled to the same consid- 
eration in this particular that are those with a due regard for the 
necessary limitations of human nature on the part of the dentist, 
and who are charitably inclined in the face of seemingly unfavor- 
able results. 

A most important consideration bearing on the decision as be- 
tween capping and destruction of the pulp relates to the length of 
time the pulp has been inflamed, and the degree of the inflam- 
matory process. The most apparent index to this is the concur- 
rent pain. If a tooth has ached violently from an exposed, or 
nearly exposed, pulp, and particularly if this high degree of in- 
flammation has continued for many hours, the conclusions are 
that the pulp has been so profoundly affected that it cannot re- 
cover, and the attempt to save it will be fruitless. But if the pulp 
has been brought under treatment in the early stages of the in- 
flammatory process, and especially if it yields promptly to pallia- 
tive treatment, the promise is greater that it may be saved. 

The question of the general health of the patient must not be 
overlooked in relation to its bearing on the probable success or 
failure of pulp-capping, nor must we lose sight of the influence 
of locality. In some regions — ^particularly in malarial districts — 
the attempt to save exposed pulps is said to invariably result in 
failure. Kepeated experiences of this nature have often led men 
who were ordinarily careful and conservative to make the state- 
ment that wherever a pulp becomes actually exposed the only 



PULP-CAPPKfG. 257 

legitimate line of treatment is to proceed to its destruction, but 
in view of the well-established fact that pulps have lived to do 
good service for many years after being capped, this must be con- 
sidered extreme teaching. The pulp is too useful under certain 
conditions — which have already been indicated — to justify an 
operator in following so radical a procedure. 

Pulp-capping, like many other lines of practice, must be studied 
with care and entered into with discriminating judgment. The 
operator must not expect success in every case, even among those 
which seem most favorable, but the fact that he has failures should 
not deter him from an honest effort to do the utmost limit for his 
patient in those cases where the preservation of the pulp seems 
desirable. 

One important consideration in this connection appears to have 
been largely overlooked by practitioners, viz, the effect on the 
peridental membrane following destruction of the pulp. It will 
be found in cases of pulpless teeth, even when there is no apparent 
discomfort and where the patient makes no complaint of the tooth, 
that there is nei'er the same resisting force in the membrane that 
was present when the pulp was alive. In other words, a patient 
can never bite down upon a pulpless tooth with the same degree 
of force that is possible on a tooth with a living pulp, and while 
this may never be noticeable in ordinary mastication, yet it im- 
plies an impairment of the membrane which should not be ignored 
as a factor in estimating the desirability or undesirability of saving 
a pulp or destroying it. 

Materials for Capping Pulps. 

Various materials have been suggested for capping pulps, each 
advocate claiming for his especial material peculiar virtues not 
found in the others. The fact that one operator will use a certain 
material with a greater degree of success than another, while the 
second will employ a different material to greater advantage than 
the first, is only another illustration of the ever-present factor of 
personal equation. We cannot eliminate this factor from con- 
sideration in any line of practice, and in the capping of pulps that 

17 



258 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

method and that material which proves most successful in the 
hands of a given operator should be the method and material for 
him to adhere to. 

And yet it may be well to consider in brief some of the various 
materials most commonly advocated for this purpose. The chief 
requisite of an ideal material would seem to be the ability to pro- 
tect the pulp against external irritation. It should therefore be a 
poor conductor of thermal changes, and should in itself be a non- 
irritant, and plastic in nature, so that when applied to the pulp 
adaptation without pressure may be attained, the mass subse- 
quently crystallizing into a rigid covering to the pulp to pro- 
tect it against external impact. 

Gutta-percha has sometimes been advocated as a pulp-capping. 
It has the advantage of being a perfect non-conductor, and it is 
also non-irritating in character, but the very nature of the ma- 
terial is such that it cannot well be accurately adapted to an ex- 
posed pulp without the danger of causing pressure, l^either can 
it be depended on to remain of uniform bulk after insertion, and 
the slight expansion which often takes place in gutta-percha may 
act as a mechanical irritant to the pulp. It is therefore seldom 
indicated for this purpose, — the factor of pressure being a very 
serious one to consider in connection with pulp-capping. 

To avoid undue pressure some operators employ a thin concave 
metal disk, placing the disk over the pulp with its concavity 
toward the pulp and the rim of the disk resting on the dentine 
around the point of exposure, and then flowing cement over this. 
A limitation to this plan would seem to be the space left between 
the disk and the pulp. JSTature's proverbial abhorrence of a 
vacuum cannot be excluded from consideration in this operation, 
and the aim should invariably be — adaptation without pressure. 

The oxychloride of zinc has also been advocated as a pulp-cap- 
ping, but its strong irritating properties would seem to limit its use 
to those pulps which will tolerate a high degree of irritation without 
dying under it. Some pulps are apparently able to live under 
severe irritation and are thereby stimulated to throw out a deposit 
of secondary dentine to protect themselves, but most pulps if sub- 



PULP-CAPPING. 259 

jected directly to the irritating influence of oxychloride of zinc 
will probably die as the result. The fact that the operator cannot 
predict with any degree of assurance just which pulps will stand 
irritation and which will not, renders the use of oxychloride a 
rather hazardous practice. 

The oxyphosphate of zinc has probably claimed more advocates 
than any other one material, it being less irritating than the oxy- 
chloride and very convenient to use. It can be flowed over an ex- 
posed pulp so as to gain adaptation without pressure, and it be- 
comes sufficiently hard to adequately protect the pulp from ex- 
ternal force. But even the oxyphosphate is somewhat irritating, — 
so much so to some pulps that it is doubtful practice to place the 
material in direct contact with an exposure. To overcome this irri- 
tating action a most excellent plan is to first make a paste by mix- 
ing the powder of the cement with some oil of cloves and place a 
thin layer of this over the point of exposure before inserting the 
oxyphosphate. This paste will effectually protect the pulp from 
the irritating influence of the cement, and it is also anodyne in its 
action and a good antiseptic. This combination of materials if 
skillfully employed will probably save any pulp that can be saved, 
and it will prove of great comfort to the patient from the fact 
that it may be employed without causing the slightest pain. In- 
stead of the oil of cloves paste some operators use a solution of 
gutta-percha dissolved in chloroform to form a film over the pulp 
before applying the oxyphosphate of zinc, but most pulps do not 
take so kindly to this as to the paste. 

Method of Capping Pulps. 

The first requisite of success is to remove all deleterious matter 
in the immediate neighborhood of the pulp by excavating the de- 
calcified and infected dentine as completely as may be short of 
wounding the pulp. The less of this infiltrated mass that is left 
in the cavity the less the danger of pulp-infection, as already 
pointed out in a previous chapter. The fluids of the mouth should 
be carefully excluded from the cavity during the cleaning and 
subsequent capping, and nothing allowed to enter except what the 



260 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

operator places there himself. The cavity should first be flooded 
with a non-irritating antiseptic, preferably the oil of cloves, and 
after wiping out the surplus with absorbent cotton the layers of de- 
calcified dentine may be peeled off with a sharp spoon excavator. 
When the cleaning is complete the cavity should again be flooded 
with the antiseptic and allowed to remain three or four minutes 
while the capping material is being prepared. When the paste 
is ready the surplus antiseptic should be removed from the cavity 
with absorbent cotton and the paste carried to position over the 
pulp. This may be done most expeditiously with a small pellet of 
tightly rolled cotton in the pliers. As soon as the paste is gently 
patted to place and the surplus removed, the oxyphosphate of zinc 
may be carried to position over it and allowed to become hard. If 
it is a case where there seems much doubt about the final saving of 
the pulp, it is well not to subject the tooth at this time to the mal- 
leting of a gold filling. The entire cavity may be filled with the 
oxyphosphate of zinc and the case dismissed for six months. If 
at the end of that time the pulp is found alive and has given no 
trouble a portion of the cement filling may be removed and re- 
placed by gold, leaving sufficient of the oxyphosphate over the 
pulp to protect it. 



CHAPTER XVIL 

DESTRUCTION OF THE PULP. 

In case it is deemed inexpedient to attempt to save a pulp, the 
necessity devolves upon the operator of destroying it and filling 
the canal. The most common method of killing a pulp is to make 
an application of arsenic to it. This may be used in the form of 
an arsenical paste prepared especially for the purpose by manu- 
facturers, to be sealed in the cavity for a longer or shorter length 
of time as the circumstances indicate. Another method of pulp- 
destruction relates to forcing a solution of cocaine into the pulp 
either by cataphoresis, by injection, or by pressure, and removing 
the pulp at the same sitting. 



DESTRUCTION OF THE PULP. 261 

The choice of methods must be governed bv the necessities of 
the case in hand, and also bj the relative success which each ope- 
rator may experience with the different methods. Some operators 
claim a vastly greater success with pressure anesthesia than with 
arsenic, while others do not find it in the least satisfactory. In a 
general way it may be suggested that wherever the operator is not 
pressed for time in the removal of the pulp, he will obtain more 
uniformly satisfactory results from arsenic than from cocaine, 
while in an emergency case where the immediate removal of the 
pulp is imperative, he mil do well to employ cocaine. 

Destroying the Pulp with Arsenic. 

The prime requisite in the application of arsenic to a pulp is 
to bring it in immediate contact with the pulp without exerting 
the slightest undue pressure upon it, and then sealing it so se- 
curely in the cavity that it cannot by any means ooze out and come 
in contact with the gums. Arsenic is exceedingly destructive to 
the tissues, and if it reaches the gums or other soft parts it will de- 
stroy them over a greater or less area, dependent upon the amount 
of arsenic and the length of time it is allowed to come in contact 
with them, often implicating the alveolar process in the destruc- 
tion. This necessitates the most careful sealing of the agent in 
the cavity, and to accomplish this without causing pressure upon 
the pulp is often a delicate procedure. Much of the pain in pulp- 
destruction that has been laid at the door of arsenic is probably 
due to pressure in its application. 

The two materials most effective in sealing arsenic may be 
said to be gutta-percha and cement, the former to be used in those 
cases where it can be applied to the surrounding walls of the cavity 
without causing pressure toward the pulp, and the latter in all 
cases where the application of gutta-percha is difficult. Cement 
may be gently flowed over the arsenic and made to adhere per- 
fectly to cavity walls without pressure on the pulp, and it is there- 
fore preferable in most cases, its chief drawback being the greater 
difficulty of removal. In proximal cavities where the cavity-wall 
slopes from the point of exposure toward the gingival margin in 




262 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

sucli a way as to present an incline down whicli the arsenic may 
easily be forced in applying the cement, the danger to the gum in 
the interproximal space is very great. An operator may readily 
force some of the arsenic into the space ahead of the cement with- 
out being aware of it till serious injury results. To avoid any 
possible danger of this nature, it is advisable in every instance 
where arsenic is to be applied to a proximal cavity to first build a 
EiG. 100. layer of gutta-percha over the gingival wall of the 
cavity leading from near the point of exposure 
down to the gingival margin of the cavity, and 
across the interproximal space against the proxi- 
mating tooth. Fig. 100. If this bridge of gutta- 
percha be thus constructed with care before the 
arsenic is applied, the operator need have no fear 
of trouble. In these cases it is well to use cement over the arsenic, 
allowing it to extend against the proximating tooth. It can be 
applied under the circumstances with less danger of pressure than 
gutta-percha, and it is not so compressible under mastication, and 
therefore less liable to be forced into the cavity so as to impinge on 
the pulp. 

The amount of arsenical paste required to destroy a pulp is very 
small. Most operators use altogether more than is necessary, and 
thereby increase to that extent the danger of injury to the sur- 
rounding parts. A minute quantity, one-half or even one-fourth 
the size of the head of an ordinary pin, if brought in immediate 
contact with the pulp will be found ample for its destruction. A 
very convenient method of applying it is to first place the required 
amount on a porcelain slab, and then with the cavity ready for its 
reception a small pellet of cotton moistened in the oil of cloves may 
be used to pick up the paste and carry it to the pulp. Let the 
paste be laid immediately over the exposure, and then release the 
pellet of cotton so that it remains in the cavity with the paste. 
Cement may then be flowed over this without danger of pressure. 
If this is dexterously accomplished there is seldom any appreciable 
pain following the application. 

The length of time necessary for the arsenic to remain may be 



DESTRUCTION OF THE PULP. 263 

judiciously varied in different cases. In yonng patients where the 
apical foramina are large, and in all cases where for any reason 
there may be doubt about the security of the sealing agent, the ar- 
senic should be removed at the end of twenty-four hours, but it i3 
seldom advisable to attempt the removal of the pulp at this time. 
While the arsenic may have effectually accomplished its purpose 
so far as the ultimate destruction of the pulp is concerned, it will 
ordinarily l)e found that sensation persists for some days after the 
application. In fact, it is usually best to wait a week or ten days 
before removing the pulp, to give ample time for the pulp to sever 
its connection at the apical foramen. Until disintegration takes 
place at this point there is always more or less sensation on its 
removal, and never the same certainty of a thorough removal to 
the apex. If the attempt is made to extract the pulp while it is 
still adherent at the apex, there is always danger of tearing the 
pulp into shreds and leaving a portion of it in the canal. De- 
composition and infection seldom follow immediately on the de- 
struction of the pulp where it is carefully sealed from the fluids of 
the mouth, so that it may safely be left a sufficient time to in-- 
sure its painless removal. In every instance where the arsenic 
is removed at the end of twenty-four hours, a non-irritating anti- 
septic should be placed over the palp and the cavity sealed with 
gutta-percha till the pulp is ready for removal. Under no cir- 
cumstances should the fluids of the mouth be allowed to enter the 
cavity after the application of the ai*senic. 

In the teeth of adults where for any reason the patient cannot 
conveniently return in twenty-four hours, and where the sealing 
may be made secure, it is permissible to leave the arsenic in for one 
week, at the end of which time the pulp may be removed pain- 
lessly. In leaving arsenic in for this length of time the greatest 
care must be exercised in sealing it, and only the minutest quantity 
of arsenic used. 

There is always the remote danger in the use of arsenic that 
the tooth may be lost through a peculiar accident whereby the 
peridental membrane is destroyed without any leaking of the 
arsenic from the cavity to the gum. This is probably due to the 



264: PKiisrciPLEs and pkactice of filling teeth. 

presence in such cases of a tributary canal leading from the pulp- 
canal proper through the side of the root. In any event such 
cases have been reported where the arsenic was left in the tooth 
only twenty-four hours, but fortunately they are very rare, — so 
much so that when compared with the very general use of arsenic 
for pulp-destruction, they may be considered only in the light 
of the remotest contingency. 

Removing the Pulp with Cocaine. 

The occasional accidents in the use of arsenic, together with 
the length of time necessary for its action, have led many operators 
to seek other means for removing the pulp. Probably the best 
method is to force a solution of cocaine into the pulp to destroy 
its sensibility, and then extract it. This may be done by taking 
some of the crystals of cocaine and making a solution by adding 
a drop or two of alcohol or chloroform, and gathering this up on 
a small pellet of cotton and placing directly over the pulp. Pres- 
sure is then applied to this in such a way as to force the solution 
into the pulp by taking a mass of unvulcanized rubber sufficient to 
fill the entire cavity, and with a broad-ended instrument driving 
this toward the pulp. The pressure should be gentle at first and 
gradually increased as the pulp will tolerate it till a very vigorous 
pumping is possible, sufficient to force the solution well into the 
pulp. If the exposure is slight, it may be necessary to make a pre- 
liminary application in this way before the operator can secure a 
broad enough exposure to carry the solution well into the pulp- 
tissue. 

This method of pulp-destruction seems in some instances to work 
almost like magic, the pulp evidently yielding at once to the in- 
fluence of the cocaine to such a degree as to permit of its removal 
without the slightest disturbance to the patient. But in many 
other cases the results are wholly unsatisfactory. It is notorious 
that cocaine does not act uniformly in all cases, and this particular 
use of cocaine seems to be no exception. With some patients the 
attempt to force cocaine into a pulp in this manner is accompanied 
with most excruciating pain, no matter how gently the operator 



DESTRUCTION OF THE PULP. 



265 



may work, nor liow patient be may be in waiting for tbe pre- 
liminary effect of tbe cocaine. In otber cases tbe most strenuous 
effort of tbe operator fails entirely in producing anestbesia of the 
pulp, tbe solution seemingly baving no effect wbatever. An- 
other minor limitation of tbe method relates to the free flow of 
blood following the removal of the pulp under these conditions. 
It is sometimes difficult to stop tbe flow so as to get tbe canal 
in perfect condition for the reception of tbe root-filling. It 
will also be found that in many cases following this kind of 
treatment a disagreeable soreness develops in tbe tooth, lasting 
several days, though seldom resulting in anything more serious 
than a temporary discomfort. This occurs oftener under this 
method than where tbe pulp has been destroyed with arsenic 
and removed in the ordinary way. 

Removal of the Pulp. 

The operation of removing tbe pulp, whether it has been de- 
stroyed with arsenic or by pressure anestbesia, is sometimes a diffi- 

FiG. 102. 

Fig. 101. ! i ! S ■^^"' ^^^' 



I 

12 3 4 

cult one, particularly in small and tortuous canals. In the larger 
canals which contain an appreciable mass of pulp-tissue tbe prob- 
lem is much simplified by the ready admission of a Donaldson 
barbed broach or an Ivory spiral broach (Figs. 101 and 102). The 
latter in a canal of sufficient size to admit it will grasp tbe pulp 



266 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

and engage it more securely than will a barbed broach, — the barbs 
sometimes exhibiting a tendency to tear through the piilp-tissue 
and fall short of extracting it, — but the barbed broach will enter a 
smaller canal than the spiral broach on account of its lesser bulk. 
In this connection it may be stated that it is hazardous to introduce 
into any canal so constricted that the broach impinges on the canal 
walls while being turned, either a barbed or a spiral broach. 

The attempt to remove pulp-tissue from constricted canals with a 
barbed broach is accountable for many a broken broach, and when 
a piece of barbed broach is thus wedged into a small canal it is 
exceedingly difficult to remove it. 

Another useful form of broach recently introduced is the Kerr 
twist broach. Fig. 103, which may be used either for the extrac- 
tion of the pulp or for reaming out and cleansing the canal. 

Before attempting the extraction of a pulp, the approaches to it 
should be opened up to give the best possible access. The roof 
of the pulp-chamber should be well cut away so that the chamber 
is exposed to view and the orifices of the canals accessible. If in a 
molar the large bulbous portion of the pulp in the chamber may 
be scooped out with a spoon excavator, leaving the openings of the 
canals exposed. The chamber should now be flooded with alcohol 
and thoroughly washed free of debris, after which warm air may 
be used to evaporate the moisture. This drying out must not be 
carried sufficiently far to endanger the integrity of the tooth-sub- 
stance, the tendency being to render teeth brittle and easily frac- 
tured when subjected to extended desiccation. And yet it would 
be very desirable if the operator could extract the moisture from 
the pulp-tissue before attempting its removal from the canals. 
The drying has a two-fold beneficial effect upon the pulp, — it less- 
ens its bulk so as to shrink it away from the walls of the canal, 
and it toughens it so that it may be more readily grasped and held 
by the broach. In many of these cases where the pulp is sensitive 
to the touch of the broach on opening up the chamber, the sensi- 
tiveness will be found materially reduced by desiccation. A pulp 
under these conditions, though sensitive to manipulation by the 
broach, is seldom sensitive to thermal changes and may therefore 



DESTRUCTION OF THE PULP. 267 

be dried without pain. To extract the moisture from the pulp 
without injuring the crown of the tooth it is sometimes advisable to 
carry the heat directly to the pulp without affecting the tooth-tis- 
sue. This may be done in many instances by following the appli- 
cation of the alcohol with a heated instrument held directly against 
the pulp-stump in each root, thus drying at least this end of the 
pulp and converting it into a leathery consistence which will facili- 
tate its removal. 

When the pulp is as dry as practicable, the broach may be car- 
ried along its side as far into the canal as it will go and then care- 
fully twisted so as to engage the pulp-tissue. If a barbed 
broach is being used, the barbed side should be placed against the 
wall of the canal and the smooth side in contact with the pulp- 
tissue while it is carried into the canal, and then so turned that 
the barbs grasp the pulp before its withdrawal. Tor removing 
pulps the broaches, whether barbed, or spiral, or twisted, should 
be used without handles, on account of the greater facility with 
which they may be made to enter the canal at the desired angle, 
particularly in posterior teeth. By grasping them between the 
thumb and index finger the operator can direct them into canals 
far back in the mouth, and reach many cases advantageously 
where a broach with a handle could never be made to enter with- 
out curving it so as to prevent a subsequent twisting for the re- 
moval of the pulp. 

In canals too small for insertion of the barbed broach — such, 
for instance, as the buccal roots of upper molars and the mesial 
roots of lower molars — the safest plan is to ream them out with 
a Kerr broach. These broaches arc exceedingly tough when 
newly made, and almost any canal may be advantageously fol- 
lowed by them to a point where the constriction is so great that 
no broach will pass. 

After the pulp-tissue is removed from the canals they should 
be flooded with alcohol to wash out any remaining fragments, and 
when thus cleaned the canals may be bathed in the oil of cloves to 
prevent any possible infection, and then flooded with alcohol once 



268 PRINCIPLES AWD PRACTICE OE FILLING TEETH. 

more previous to the final drying for the reception of the root- 
filling. If the pulps have been successfully removed and the 
canals rendered clean and aseptic, the roots may be filled at the 
same setting. 



CHAPTEE XVIII. 

FILLING PULP-CANALS. 

The selection of a suitable filling-material for pulp-canals is a 
question that has engaged the minds of the profession ever since 
pulpless teeth have been considered worthy of saving. Without 
going into the history of the various materials that have from time 
to time been advocated, it is sufficient to say that the most uni- 
versal practice to-day is to use gutta-percha. This material has pe- 
culiar qualities entitling it to favor for this purpose, and while it 
cannot be considered ideal in all respects it probably fulfills the re- 
quirements to a greater degree than any other one material. It is 
a non-conductor and a non-irritant. It can be molded to fit the 
inequalities of any canal, and be made to follow a constricted and 
tortuous canal, particularly if used in the form of a solution. This 
solution is ordinarily made by dissolving gutta-percha in chloro- 
form to a cream-like consistence, and then pumping this into the 
canals, after which a cone of solid gutta-percha is forced into the 
canal to displace all of the solution possible and leave as much 
as may be of the canal filled by solid gutta-percha. 

One limitation of the chloro-percha solution consists in the fact 
that the chloroform is so readily evaporated that it is difficult 
to keep the solution of a proper consistence for daily use. To 
provide a solution for this purpose which will remain stationary, 
it is suggested that when the gutta-percha is dissolved in chloro- 
form and the latter begins to evaporate the loss of fluidity be made 
good by the addition of eucalyptol. This may be carried on till 
all the chloroform is gone and the solution consists entirely of 
gutta-percha and eucalyptol. 

This solution is to be used not with the idea of forming a root- 
filling of itself, but merely as a moistening agent for the canals 



FILLING PULP-CANALS. 269 

preparatory to the introduction of the solid gutta-percha, which 
latter will follow up a canal to better advantage under these con- 
ditions than if inserted in a dry canal. 

The modus operandi of filling canals with gutta-percha is to 
first flood them with the solution by dipping a small pellet of cot- 
ton in it, and carrying this to the pulp-chamber and squeezing it 
out against the side of the chamber. This will cause the solution 
to flow into the canals. Then, with a smooth broach, pump the so- 
lution well into the canals, and thereby displace the air from the 
canals by carrying the solution to the apex. In constricted canals 
this pumping with the broach should be quite vigorous, but in 
larger canals there is not the same necessity for extended manipu- 
lation with the broach, on account of the ready flowing of the 
solution to the apex and the subsequent insertion of the gutta- 
percha cone. In fact, too much manipulation with the broach in 
large canals is to be avoided, on account of the possible danger 
from irritation beyond the apex. The aim should be in these cases 
to carry the solution and the cone just to the apex and no farther. 
This is often a delicate matter, but by a close study of these cases 
the operator may be reasonably certain as to the moment the apex 
is reached. There is no rule which may be taught as an infallible 
guide to indicate just when the apex is reached. It has some- 
times been suggested that the evidence of an approach to the api- 
cal foramen was furnished in a flinching of the patient, but this is 
by no means reliable. In some instances where the foramina are 
very small at the apex, and where there is no sensitive tissue be- 
yond the root, we may secure a most thorough filling of the canal 
without the slightest sensation to the patient. To keep on pump- 
ing at a case of this kind looking for a response from the patient 
would be mistaken zeal, and might cause subsequent irritation. 
On the other hand, there are cases where the slightest pressure 
exerted on the contents of a canal, even where the pressure is so far 
removed as the entrance to the canal at the pulp-chamber, will 
cause a ready response. This may be due to the pressure of air 
in the extremity of the canal, and a response of this kind would be 



270 PRINCIPLES AND PRACTICE OF PILLING TEETH, 

no indication whatever that the filling-material had reached the 
apex. 

The whole question is one of intuitive perception on the part 
of the operator, and of such a training of the faculties and fingers 
that the sensation conveyed to the practitioner is the keynote, and 
not the sensation conveyed to the patient. 

When the canals are filled with the solution a solid gutta-percha 
cone should be grasped by the pliers and carried into each canal, 
thereby displacing a part of the solution. If the canal is so large 
that the ordinary cones supplied by the manufacturers are not 
large enough to fill it, a second one may be forced in beside the 
first, or a cone may be made by the operator for the case in hand. 
Considerable pressure should be exerted on the cone to make it fit 
up tight to the canal at the apex. Ordinarily the large end of the 
cone will be found standing up in the chamber after it has been 
forced as far as possible into the canal, and if a heated instrument 
is applied to this in the attempt to compress it toward the canal, 
the tendency is for the cone to adhere to the instrument and be 
withdrawn from the canal. Instead of heating the instrument, 
the end of the cone should be heated by directing a blast of hot air 
upon it, and then a broad-ended instrument may be used to com- 
press it to place. In some instances, particularly in three-rooted 
teeth where the chamber is large, it may be well, before attempting 
to compress the large ends of the cones, to wann a pellet of gutta- 
percha and force this to place against the floor of the chamber or 
subpulpal wall, and then gather the ends of the cones over into the 
pellet and incorporate the whole in one mass. In doing this the 
end of the plugger may advantageously be wiped off with a cloth 
saturated with one of the essential oils, which will to a large degree 
prevent the adhesion of the gutta-percha to the instrument. 

The case now presents with the cones in place and the floor of 
the chamber covered with gutta-percha, but the canals must not 
be considered perfectly filled. There is yet too much of the solu- 
tion remaining, and this must be as largely displaced as possible 
by the solid gutta-percha. To do this a root-canal plugger should 
be warmed and wiped with the oiled cloth, and gently forced into 



THE TREATMENT OF PULPLESS TEETH. 271 

the canals in such a way as to drive the gutta-percha more snugly 
into them. As the gutta-percha is compressed into the canals the 
solution will ooze out around the margins, and may from time to 
time he absorbed with a pellet of cotton. This forcing process 
should be continued till there is assurance that the canals are 
solidly filled with gutta-percha and all the surplus solution re- 
moved. Over the gutta-percha thus inserted a layer of cement, 
preferably the oxychloride of zinc, should be used upon which to 
build the permanent filling. Gutta-percha does not present a 
sufficiently firm or stable base to justify an operator in building a 
metal filling upon it. 

In case there is no pericemental soreness the operation may 
be completed with a permanent filling — whether of amalgam or 
gold — at the same sitting, but if there is irritation present the 
cavity should be temporarily sealed and the case dismissed for a 
few davs till the soreness subsides. 



CHAPTER XIX. 

THE TREATMENT OF PULPLESS TEETH. 

When a pulp dies in a tooth without the aid of the operator, the 
management of the case is different from that of a recently de- 
stroyed pulp where the tooth has been under the operator's super- 
vision from the destruction of the pulp to the final filling of the 
root. The question of infection enters materially into the case 
so soon as the natural processes of dissolution are allowed to run 
their course without interference. 

Cases of this character may be divided into three classes, — those 
where the pulps die as the result of the approach of caries, and 
which come to the operator with the cavity and canals exposed to 
the fluids of the mouth; those where the pulps die under a filling, 
and those in perfectly sound teeth where the pulp has been lost 
as the result of .some injury. 

Each of these classes may present in one of the following condi- 
tions: There may be no apparent disturbance beyond the apex of 



272 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

the root, with no soreness or inflammatioiQ of the peridental mem- 
brane and no pus, or there may be decided soreness with an 
elongation of the tooth from a swelling of the membrane, or there 
may be an abscess of soreness with a pus pocket beyond the apex 
but no external opening, and lastly, there may be an abscess with 
a fistula passing through the alveolar process and opening on the 
gum. 

Treatment of Pulpless Teeth where the Canals have been Long 
Exposed to the Fluids of the Mouth, but where there is No 
Fistulous Opening. 

These cases must always be treated with the possibility in mind 
that there may be a blind and passive abscess in the apical space 
which is quite likely to develop into a fiery furnace by a little 
mismanagement. The actual decay in the cavity should first be 
thoroughly removed and the pulp-chamber well opened up. This 
must be done without the slightest manipulation of the contents 
of the canals, or the least pressure that is calculated to force any- 
thing through the apical foramen. This preliminary cleansing 
of the cavity may be done without the application of the rubber 
dam, and the debris may be rinsed out from time to time with a 
syringe. Make the cavity and chamber as mechanically clean as 
possible. Then apply the rubber dam and absorb the moisture 
from the cavity with cotton. Flood the cavity and chamber with 
alcohol, which has a great afiinity for moisture, and absorb the al- 
cohol with cotton. This will often extract some of the discolored 
and putrescent contents of the canals. Wash out well with alco- 
hol in this manner till the alcohol fails to be discolored by contact 
with the cavity and chamber. Then dry the chamber and as much 
of the canals as possible with warm air, but do not carry the desic- 
cation so far as to weaken the tooth-structure. ISTow flood the 
canals and chamber with a non-irritating antiseptic, a good one be- 
ing the oil of cloves. The canals must not at this sitting be en- 
tered by a broach, and no attempt made to clean them by instru- 
mentation except in a slight degree in those cases where the canal 
is very large and filled with debris and putrescent matter. A 



THE TREATMENT OF PULPLESS TEETH. 273 

canal like this when flooded with the medicament may sometimes 
be approached very gently with a smooth broach, and the debris 
carefully coaxed out and floated away from the larger portion of 
the canal without disturbing the contents near the apex. The 
reason that great care is necessary in the preliminary treatment of 
these cases is because if the slightest bit of this putrescent matter 
be forced through the apical foramen it is almost certain to set 
up a serious inflammatory process which may run to abscess. 
After the chamber and canals have been flooded with the anti- 
septic, some cotton saturated with it may be loosely placed in the 
chamber and the cavity sealed with gutta-percha. For this pur- 
pose the temporary stopping may be used to good advantage, on 
account of its being easier of manipulation than the base-plate 
gutta-percha. 

If it has been possible to secure a reasonably perfect cleansing 
of the tooth and there seems to be little putrescence left in the 
canals, the case may be dismissed for one week, with instruction 
to report at once in case of trouble. It should be the aim of the 
operator from this time forward to allow nothing in the tooth ex- 
cept what he places there, and if trouble ensues it is better for the 
patient to seek the operator and let him change the dressing rather 
than to pick out the gutta-percha and again admit the fluids of the 
mouth. 

In case the dentine seems badly infiltrated with putrescence and 
the first treatment has apparently failed to control it to the opera- 
tor's satisfaction, he would better not let the case go a week. Un- 
der these conditions the tooth should be seen in twenty-four or 
forty-eight hours and the treatment repeated. After this second 
dressing the case may be dismissed for a week. If the tooth re- 
mains sealed up for this time without discomfort, the operator may 
safely proceed to clean out the canals. They should first be 
flooded with alcohol and manipulated gently with a smooth broach 
to float any particles of debris that may have been packed into 
them. Even at this second sitting the operator should guard 
against undue irritation of the apical tissues by the broach. He 

18 



274 PRINCIPLES AND PRACTICE OF PILLING TEETH, 

should aim to make his cleansing as thorough as possible without 
forcing anything through the apex. 

This mechanical cleansing of the canals is a very important 
part of the successful treatment of pulpless teeth. When it is 
remembered that the cases at present under consideration are those 
in which the contents of the canals have long been subjected to the 
iniluences of infection and the dentine itself is more or less infil- 
trated with poisonous material, it must be apparent that the most 
thorough cleansing with instruments should supplement any or 
all kinds of medication. Many operators rely too largely upon 
the efficacy of drugs as a short cut to excuse them from the neces- 
sity of painstaking care in removing mechanically every particle 
of the putrid contents of canals. Medication is necessary, but it 
can never be fully effective without the aid of instrumentation. 

To be successful in the mechanical cleansing of canals it is im- 
portant to first gain the best possible access. The orifices of canals 
leading from the pulp-chamber are often constricted and unap- 
proachable, — so much so in some instances as to make it difficult 
to find the openings. If the chamber is well uncovered these 
openings may readily be found by following a simple procedure. 
Flood the chamber with alcohol and evaporate it with warm air, 
when the openings will ordinarily be plainly visible as soon as the 
floor of the chamber is dry. These orifices should at once be 
widely reamed out with a large Gates-Glidden drill, — a drill too 
large to be admitted into the canal proper, — so as to form a funnel 
leading to the canal. This reaming out will perfectly expose the 
approach to the canal and permit the operator to ascertain the 
nature of the canal and its general direction. This should be care- 
fully determined with a smooth broach, and in cases of constricted 
canals the proper cleansing and medication of the canal involves 
its enlargement by the operator. 

This question of the enlargement of canals is one of the most 
intricate connected with the treatment of pulpless teeth. The at- 
tempt to enlarge canals with drills in the hands of careless or in- 
competent operators has been prolific of disaster. It is manifestly 
impossible to follow a curved canal with a drill, and the inevitable 



THE TREATMENT OF PULPLESS TEETH. 275 

result has been that operators have drilled through the side of the 
root The frequency of this accident has led many conservative 
men to make the statement that a drill should never be used 
for enlarging canals, and yet in the hands of a careful operator 
this instrument is one of the most useful we have in the manage- 
ment of these cases. It is seldom that such canals as those in 
the buccal roots of the upper molars, the mesial root of the 
lower molars, or the bifurcated root of an upper first bicuspid 
can be properly cleaned without a slight enlargement. Then 
again there are many of the larger canals in which there is 
an unevenness along the walls or a flattening of the canal which 
requires a reaming out to be properly treated and filled. In 
very many instances this may be safely and quickly accom- 
plished with a drill, — at least in the first third or half of the 
canal, — provided the operator can secure the proper approach to 
it, and will first study the direction of the canal with a broach. 
Unless he can so hold the drill that the approach is at the proper 
angle, he would better not attempt to drill at all. Any undue 
bending of the drill while it is revolving in a canal, or any binding 
or clogging, is quite likely to result in the drill being broken and 
lodged in the canal. The greatest care should be taken to avoid 
this, and consequently it is never permissible to exert much force 
on the drill nor to attempt to drill around a corner. In many 
instances in the molars and bicuspids the drill should be used in 
the right-angle hand-piece to admit of the proper approach. It 
should be passed back and forth in the canal with the slightest 
pressure, so that the cutting is done without clogging, and most 
of the lateral reaming should be done on the withdrawal move- 
ment of the drill instead of on the forward movement. 

If the drill is thus used with care and never forced too near the 
apex it is capable of great usefulness in the preparation of roots 
for filling, but there are some cases where the canals are so curved 
and the approach so difficult that it is injudicious to attempt to 
place a drill in them at all. In such cases the canals may be en- 
larged by the method suggested by Dr. J. K. Callahan, whereby 
a solution of sulphuric acid is used to soften the walls of the canals 



276 PKiNciPLEs AjStd practice of filling teeth. 

so that tliej may be readily scraped out and enlarged with a Don- 
aldson cleanser. The manner of using the sulphuric acid is as fol- 
lows: A forty per cent, solution of commercial sulphuric acid 
should he prepared and kept in a glass-stoppered bottle. A drop 
or two of this may be carried to the canals by winding some fibers 
of cotton on a wooden point, and dipping this in the solution and 
pressing the soaked cotton against the side of the chamber till the 
solution flows down into the canals. This should then be pumped 
to place with a piano-wire broach, — ^using a new broach each time. 
When the smooth broach will readily pass back and forth in the 
canal, a Donaldson cleanser or Kerr broach may be used to further 
pare away the sides of the canal and enlarge it. As soon as this 
is accomplished to the satisfaction of the operator the chamber and 
canals should be freely flooded with a saturated solution of sodium 
bicarbonate to neutralize the further effect of the acid, and this 
should be continued till all effervescence ceases. The canals 
should then be dried out by flooding them with alcohol and evap- 
orating it either with warm air or a heated root-canal drier. The 
latter is ordinarily preferable on account of the danger to the 
crown of the tooth by the use of air. The fact should always be 
noted that it is unsafe to overheat or unduly dry the tooth-tissue 
on the crown, and a better drying of the canal can be attained 
without jeopardy to the crown by the use of a canal drier than 
with a diffused blast of warm air. As soon as the canal is dry it 
should immediately be flooded with the oil of cloves, which mil 
under these conditions penetrate not only to the apex of the root, 
but be absorbed more or less by the open ends of the dentinal 
tubuli leading from the canal. 

If the case has progressed favorably up to this point and there 
are no untoward symptoms, the canals may be filled at this sitting. 
Preparatory to this the oil of cloves should be wiped out and some 
more alcohol used for dryness. The moment the canals are dried 
the eucalyptol solution should be at hand for use, so that the den- 
tine is not kept desiccated for any length of time. 

In those cases where the canals have long been exposed to the 
fluids of the mouth there is always the possibility of an abscess 



THE TREATMENT OF PULPLESS TEETH. 277 

occurring in the apical space and discharging through the tooth, 
thus giving no external evidence of its existence. In such cases 
the operator will ordinarily be able to detect the presence of pus 
either in his preliminary work on the canals, or at least on the cot- 
ton after it has been sealed in the tooth. As soon as pus is demon- 
strated the management of the case is slightly changed. The 
canals should at once be thoroughly cleansed, and all the pus re- 
moved that is possible by coaxing it from the apex toward the 
chamber with a broach, and then absorbed with cotton or with 
bibulous paper cones prepared for this purpose. When no more 
pus can be extracted the canals should be flooded with an antiseptic 
and some cotton placed in the chamber, and the cavity sealed. If 
there has been much pus, and particularly if it has been of an 
offensive character, the case should be seen in twenty-four hours 
and the treatment repeated. At the second sitting the condition 
of the case will indicate the line of treatment. If there has been 
perceptible improvement there need be very little manipulation 
with the broach, but merely a change of dressing. If the pus 
seems as bad as ever the broach should be freely used, and in some 
instances it will be found beneficial to work with the broach till 
all pus is removed and a tinge of blood follows it into the canal. 
As soon as the blood shows it is well to pack the canal with cotton 
saturated with the antiseptic, and seal the cavity. Under these 
conditions the case may be dismissed for a week with instructions 
to report in the event of trouble. If at the end of this period there 
is still pus, it is well to inject peroxide of hydrogen into the abscess 
and let it effervesce through the tooth. Peroxide of hydrogen is 
not indicated at the outset before the canals have been disinfected, 
through fear of irritation following the effervescence. This dan- 
ger is not so great after the first treatment. When effervescence 
has ceased the canal may again be packed with an antiseptic, and 
the case dismissed for two weeks. After the first thorough dis- 
infection of the canal the tooth should not be treated frequently, 
unless the operator is forced to do so by pain. Many of these 
cases are kept in a state of irritation by too much operative inter- 



278 PRINCIPLES AND PRACTICE OF PILLING TEETH, 

f erence, and it will often be found a very effective practice to give 
nature a chance. 

Wlien tlie character of the discharge changes from a thick yel- 
lowish pus to a thin serous fluid, — ^which is very frequently the 
case, — the canal should be packed tight to the apex with cotton 
saturated in an antiseptic, and the case left long enough to give 
it an opportunity to dry up. Except in stubborn cases this will 
usually occur in two weeks, and when the tooth has remained for 
that length of time free from trouble, while tightly sealed, it may 
be considered safe to fill it, provided the canal can be perfectly 
dried to the apex. 

Treatment of Pulpless Teeth having a Fistulous Opening on 

the Gum. 

Whether the fistula proceeds from a tooth with a filling in it or 
with an open cavity, the first treatment involves the thorough 
opening up of the chamber and canals, and the most painstaking 
cleansing to the very apex if possible. With a fistula leading from 
the abscess there is little danger of setting up inflammation by the 
use of broaches or drills in the canals, and the more thoroughly 
this initial cleansing is done the more readily may the abscess be 
brought under control. After the canals are cleansed, the one 
from which the abscess comes — a fact which may usually be de- 
termined by passing a probe into the fistula and tracing its direc- 
tion — should be packed with cotton saturated with a non-irritating 
antiseptic such as the oil of cloves, and pressure brought to bear 
upon it so as to force the agent through the fistula till it appears on 
the gum. This may ordinarily be best accomplished by placing 
a mass of unvulcanized rubber into the cavity and exerting pres- 
sure upon it with a broad-ended instrument with a pumping mo- 
tion toward the orifice of the canal. This will cause compression 
on the contents of the canal and force the medicament through 
the fistula. As soon as it appears on the gum the rubber may be 
removed and the cotton changed for a freshly saturated piece, and 
the cavity sealed for one week. Usually the fistula will be found 
healed at the end of this time if the first treatment has been thor- 



THE TREATMENT OF PULPLESS TEETH. 279 

ough, but in case the fistula still persists the treatment may be 
repeated. When a case exhibits this tendency to a chronic con- 
dition it is well at the second treatment to substitute carbolic acid, 
ninety-five per cent., for the essential oil. It is a rare case indeed 
which will not heal in response to a thorough injection of this 
agent through the fistula. The same rule in regard to waiting to 
give nature a chance after the first or second treatment should be 
followed here as with the previous cases under consideration. Many 
a chronic case will heal in two weeks when it will not heal in one. 
In case a second or third injection of the carbolic acid fails to 
close the fistula it may be taken for granted that there is some 
caries of the process surrounding the apex of the root, or such a 
roughening of the end of the root as to prevent the tissues from 
healing over it. Under these conditions the root-canal should be 
filled and the external fistula packed with cotton to enlarge it. 
The cotton should be changed every twenty-four hours for a larger 
piece till the fistula is sufficiently expanded to permit of perfect ac- 
cess to the end of the root. When this is attained a sharp bur in 
the engine should be used to ream out the carious bone and smooth 
the rough end of the root, — if necessary, cutting off a piece of the 
root. The opening thus made should be syringed out with an an- 
tiseptic solution and freely plastered with a paste made by mixing 
boracic acid with oil of cloves, after which some antiseptic gauze 
should be packed into it to keep it from healing at the orifice be- 
fore granulations have perfectly filled in the interior. The dress- 
ing should be changed every twenty-four hours, and as the open- 
ing heals from within the gauze may be made less and less till it is 
not required at all. This will cure the most stubborn case, — and 
it may be said, in passing, that it is only the very stubborn cases 
that call for it, the vast majority of abscesses usually healing 
without recourse to such surgical interference. It should be the 
aim of the operator to cure all cases, if possible, by treatment 
through the pulp-canal in the ordinary way, but where this opera- 
tion seems imperatively necessary it must not be considered a very 
serious or formidable one. A little delicacy on the part of the 



280 PKINCIPLES AND PKACTICE OF FILLING TEETH. 

practitioner will usually enable him to perform it without ap- 
preciable pain to the patient. 

Opening into Filled Teeth in which the Pulps have Died, but 
have Lain Dormant. 

It will occasionally be found that pulps die under fillings with- 
out giving any particular trouble to the patient, and the tooth re- 
mains passive for an indefinite time with no indication of abscess. 
In opening into these teeth for the purpose of treating and filling 
the canals the very greatest care is necessary to avoid trouble. 
There seems to be a disposition in such cases for the most active 
inflammation to ensue the moment an opening is made through the 
filling. This is all the more embarrassing to the operator in view 
of the fact that the trouble dates from the time of his interference 
with the case, and it is sometimes difficult to explain to the patient 
that it is not due to his carelessness. These cases should therefore 
be approached with the utmost caution, and everything should be 
in readiness for immediate medication the moment the drill pene^ 
trates through the filling. On account of its dehydrating proper- 
ties, alcohol would seem to be the best agent for the first flooding 
of the cavity. This should be conveniently at hand, and at once 
admitted to the opening when the drill passes into the chamber. 
After letting it remain a moment, the surplus may be absorbed 
with cotton followed by warm air till the cavity is dry. The 
opening through the filling may be then enlarged as indicated, and 
the cavity again flooded with alcohol. A very gentle stirring of 
the alcohol in the chamber is permissible with the object of wash- 
ing out any debris or putrescent matter that may be present, but 
no attempt should be made to use instruments in the canals 
through fear of forcing infectious matter beyond the apex. After 
the chamber is well washed with alcohol it should be dried again, 
and a pellet of cotton saturated with oil of cloves placed loosely 
in the chamber and the opening sealed with gutta-percha. The 
subsequent management of the case is the same as that already out- 
lined for the treatment of pulpless teeth having no fistulous open- 
ings. 



THE TEEATME^TT OF PULPLESS TEETH. 281 

The Management of Pulpless Teeth in the Anterior Part of the 
Mouth to Prevent Discoloration. 

The tendency of all pulpless teeth to take on discoloration ren- 
ders it necessary for the operator to exercise especial caution with 
teeth exposed to view, to avoid as largely as may be the resultant 
disfigurement of his patient. If a pulp must be lost in an incisor, 
it is preferable, if possible, to destroy it by means of pressure an- 
esthesia rather than to apply arsenic, on account of the fact that 
many cases are on record where the application of arsenic has re- 
sulted in a sudden clouding of the tooth from the active inflam- 
mation induced. If it is deemed necessary to use arsenic, only 
a very small quantity should be used, and it should not be allowed 
to remain longer than twenty-four hours. At the end of thia 
time the arsenic should be removed, and the cavity washed out 
with alcohol and dried, after which some light-colored antiseptic 
may be sealed in the cavity for one week, — using cement as the 
sealing agent. It should be a cardinal principle in the treatment 
of these cases never to allow the fluids of the mouth to gain en- 
trance to the cavity after the case comes under the care of the 
operator, and in the sealing of medicaments it is safer to use 
cement than gutta-percha. The latter may not be so permeable 
to moisture under long-continued exposure as the former, but the 
ready adaptation and adhesion of cement to cavity-walls renders 
it the most certain sealing agent. Along this same line no treat- 
ment should ever be made without the application of the rubber 
dam. 

As soon as the pulp is removed and the canal dried the root 
should be filled, and, if possible, a permanent filling inserted in 
the crown at the same sitting. If these precautions are taken it 
will seldom be found that a tooth becomes sufficiently discolored 
to be noticeable. 

Bleaching Teeth. 

It is scarcely within the province of the present work to go 
minutely into the subject of treating discolored teeth, but a simple 
suggestion may be made as to a certain method of bleaching which 



282 PRINCIPLES AND PRACTICE OF FILLING TEETH. 

will be found effective in a large percentage of cases applying to 
the operator. When a tooth presents which has become dis- 
colored as the result of loss of the pulp, the first consideration is 
to put the canal in a healthy condition and fill it. Then the tooth 
may be bleached in the following way : The root-filling should be 
removed sufficiently to allow the bleaching agent to act on the 
tooth well under the line of the free margin of the gum, — many 
of these cases showing the most marked discoloration near the 
gum. The cavity should then be dried out, and a pellet of cotton 
saturated with a fresh solution of the twenty-five per cent, pyro- 
zone should be sealed in the cavity with cement for twenty-four 
or forty-eight hours, at the end of which time a very perceptible 
bleaching will ordinarily have occurred.. In some stubborn cases 
it may be necessary to repeat the treatment, — always being careful 
to apply the rubber dam at each sitting, and invariably sealing 
with cement. If this method is carefully followed the results are 
usually very gratifying and the bleaching quite permanent. 

Another effective way of bleaching where it is desired to ac- 
complish the purpose at a single sitting has been suggested by Dr. 
J. P. Buckley, of Chicago, as follows : 

"The dam is placed over the tooth and adjacent teeth. A thin 
platinum band is wrapped around the tooth to be bleached and 
white gutta-percha warmed and used to form a pocket about the 
cavity. By the use of a small gold or platinum spoon some sodium 
dioxide is placed in the cavity and forced some distance up the 
root-canal with a glass instrument. Distilled water is now dropped 
into the cavity, and a piece of platinum held over the cavity to 
force the generated oxygen into the dentine. After sufficient time 
to allow the oxygen to work, the cavity should be washed and dried 
and the operation repeated if necessary. Should it be found im- 
possible to remove the pigment mechanically with water, a 3 per 
cent, solution of sulphuric acid may be used to chemically dis- 
solve it, after which wash with water and let dry, preferably with- 
out using hot air. ISTow burnish a paste of precipitate calcium 
phosphate and distilled water into the lower third of the root and 



THE MANAGEMENT OF CHILDEEn's TEETH. 283 

against all exposed dentine. Make a base for final filling, using 
light-colored cement." 



CHAPTER XX. 

THE MANAGEMENT OF CHILDEEN'S TEETH. 

This subject presents itself in two phases for our consideration 
from an operative point of view, — the care of the deciduous teeth, 
and the care of those of the permanent set which may be said to 
appear in childhood. The problems which confront the operator 
in the one case are not precisely the same as those in the other, and 
the intelligent practitioner will study the two situations from a 
somewhat different basis. The object in the management of the 
deciduous set is merely to do palliative work, with the idea of 
keeping the patient comfortable for a period of a few years, rather 
than to undertake thorough, permanent, and artistic operations. 
The avoidance of pain at this stage is very important, and this of 
itself often involves the performance of temporary work. While 
the operator is not by any means free from this restriction in his 
management of the permanent teeth, particularly those which ap- 
pear early, yet his aim as he approaches these should be in the di- 
rection of attaining the greatest possible permanence to his opera- 
tions, \vith the idea ever in mind that the highest exercise of his art 
involves the saving of these organs for a lifetime. 

Management of the Deciduous Teeth. 

The impression among many of the laity that these teeth may 
well be neglected, so far as operative procedures are concerned, on 
the basis that they are eventually lost through natural processes, 
should be corrected by the profession at every opportunity. Be- 
yond the patent fact of much possible suffering on the part of the 
patient and much injury to the health through neglected and ab- 
scessed teeth, there is a question of habit Avhich would seem to have 
an important bearing on the future welfare of the patient. These 
little folk are very impressionable at such a tender age, and readily 
acquire habits which may conduce to either their permanent bene- 



284 PRINCIPLES AND PEACTICE OF PILLING TEETH, 

fit or injury. If a deciduous tooth, decays and is allowed to go 
without attention, it sooner or later becomes sensitive to the impact 
of food in mastication, and the little patient often, without being 
able to explain the real source of the discomfort, intuitively avoids 
■chewing upon the side of the mouth affected. This leads to im- 
perfect mastication, and where there are several sensitive teeth in 
the mouth it may lead to an almost entire cessation of mastication; 
so that a process of bolting the food is inaugurated which may, and 
undoubtedly often does, cling to the patient as a habit through life. 

If a close observer will carefully note the workings of mastica- 
tion in the mouths of the individuals he meets, he may of course get 
& reputation for rudeness, but he will also be impressed with the 
variations in the methods practiced and the degree of effectiveness 
exemplified in the different mouths. These variations occur in 
individuals who have teeth of relatively equal efficiency, so that 
they must be traced largely to matters of habit; and it is natural to 
conclude that these habits were formed in childhood. When it is 
considered that effective mastication is a weighty factor in the 
health and longevity of the individual, it may be seen how impor- 
tant it becomes that we keep the teeth of children in a condition 
comfortable under the trituration of food and conducive to habits 
of thorough mastication. 

A child should be brought to the dentist at regular intervals for 
examination from the time of the third, or at latest the fourth, year 
of age. The first operation usually necessary is fortunately that 
of cleaning the teeth, and this may be accomplished as a sort of a 
frolic on the part of the little patient and without any pain. If the 
teeth are cleaned several times before any filling becomes neces- 
sary the dread of the dental chair is largely overcome, and filling 
operations are undertaken with a better prospect of success. 

The materials to be used for filling the deciduous teeth are ordi- 
narily limited to gutta-percha, cement, and amalgam. For the 
anterior teeth cement must be considered the chief reliance, on 
account of the nature of the decay which usually attacks these 
teeth. The cavities are for the most part shallow and not well 
defined in outline, nor is it possible in many instances to establish a 



THE MANAGEMENT OF CHILDREN'S TEETH. 285 

perfect outline or trim to a well-formed margin. After the re- 
moval, more or less thoroughly, of the decay, the filling must be 
plastered against the decayed surface and remain by its own ad- 
hesive properties. Cement is the only material which can be 
relied upon to do this, the fact that it is necessary to renew it occa- 
sionally being its chief limitation. It is ordinarily not a very difii- 
cult problem to save the deciduous incisors and keep them comfort- 
able till the eruption of the permanent ones, on account of the early 
age at which they are shed; but the care of the deciduous molars 
becomes a more serious matter. They are usually retained four 
or five years longer than the incisors, and those years are sometimes 
very trying both to patient and operator. Occlusal cavities in 
these teeth are ordinarily easily managed with either cement or 
amalgam, the choice being governed by the degree of thoroughness 
with which the cavity may be excavated without pain. If a good 
preparation can be made, and the pulp is not too nearly involved, 
amalgam should be used on account of its greater permanence, but 
in some instances the teeth are so sensitive that the most that can 
be accomplished is to break down the thin overhanging enamel- 
walls, remove the softer portions of the carious dentine, and force 
cement into the cavity. When cement is used under these condi- 
tions it should be placed in position with considerable pressure. It 
should also be used in such excess that the entire occlusal surface of 
the tooth is covered even beyond the borders of the cavity, so far 
as this may be done without interfering with the occlusion. To 
accomplish this conveniently, and also to protect the filling from 
moisture for a few minutes without stuffing the mouth full of 
napkins or absorbent rolls, the index finger of the operator may be 
brought down upon the cement as it lies on the tooth and the whole 
occlusal surface subjected to pressure, so that the cement will be 
forcibly carried into every groove or inequality on this surface and 
the excess be squeezed out over the marginal ridges of enamel. 
If the finger be held upon the cement a few minutes the result is a 
filling which not only includes the cavity itself, but also protects 
the grooves and other vulnerable points radiating from it. 

The problem of chief concern in the care of these teeth relates to 



286 PRINCIPLES AND PKACTICE OF PILLING TEETH. 

the management of occluso-proximal cavities. There are two fac- 
tors which, tend to make these cavities especially difficult to con- 
trol, — the almost universal sensitiveness which we find present, 
thus preventing an adequate preparation of the cavity to retain the 
filling, and a gradual separating of the teeth from the natural ex- 
pansion of the jaw, so as to lead to constant complaint on the part 
of the patient of food wedging between the filling and the proxi- 
mating tooth and lodging in the interproximal space. This dis- 
comfort is often manifest as the teeth drift apart, even when no 
decay has occurred, but it is particularly annoying between filled 
teeth where it has not been possible to contour sufficiently to main- 
tain perfect contact with the proximating tooth. The insecurity 
of anchorage usually imposes upon the operator the alternative of 
making fillings with limited contour, and this soon leads to a 
pocket between the teeth, which proves a constant source of dis- 
comfort. 

Ordinarily where the proximal surface of a molar is decayed 
the proximating surface of the one next to it also becomes in- 
volved, and this complicates matters so far as making separate fill- 
ings is concerned. In desperate cases, where both teeth are de- 
cayed, it may be advisable to bridge across the interproximal 
space and join the fillings together. This will at once do away 
with the difficulty of food wedging between the teeth, and will 
often prove a relief to the patient where separate fillings have been 
a failure. But there are only two materials which are suitable for 
this purpose. If cement is employed it is only a matter of a few 
weeks when the whole mass is found loose between the teeth; so 
that the operator is limited to gutta-percha and amalgam. If the 
former is used it will ordinarily not draw away from either cavity, 
and it is excellent as a temporary expedient, but it is so easily worn 
out that it is at best only a makeshift. Amalgam is probably the 
most serviceable material for these cavities. It is not worn away 
by attrition, and will remain more securely fixed than cement, 
though in some instances the case will present in a few months with 
the filling loosened from one of the cavities while the other remains 
firm. The reason for this lies in the individual movement of the 
teeth, the one with the lesser retention giving way. 



THE MANAGEME^'T OF CHILDEEn's TEETH. 287 

A great aid in securing firmness of these fillings when joined to- 
gether, no matter which material is used, is to first place a metal 
bar across the interproximal space, with one end resting on the 
gingival wall of one cavity and the other on the gingival wall of 
the other, and building the fillings around and over it. This locks 
the teeth together more securely, and affords perfect protection to 
tiie gum. These bars may conveniently be made from German 
silver wire rolled flat, and cut to a suitable length for the case in 
nand. 

This operation is, of course, contra-indicated, except in the most 
desperate cases, on account of its evident limitations, but as a 
temporary expedient it will often be found of service in rendering 
the little patient comfortable. 

Treatment of Exposed Pulps in Deciduous Teeth. 

When a pulp becomes exposed in a deciduous tooth, it is seldom 
advisable to make an application for its destruction. If the patient 
applies with pain this can ordinarily be quickly relieved by syring- 
ing the cavity well with tepid water to remove loose debris, and 
carefully clearing away with a spoon excavator any hard material 
which may be causing pressure on the pulp. This is to be followed 

s^e of the head of a pm, covered with dry cotton to fill the cavity 
When the pam is relieved, it is better to treat the tooth in a pallia- 
tive way than to subject the pulp to the action of drugs sufficiently 
powerful to work its destruction. Arsenic should never, under 
any circumstances, be used in a deciduous tooth. The risk is too 
great of doing serious injury to the surrounding parts, and the 
necessities of the case seldom call for any such radical treatment 

An exposed pulp may be treated by flowing over it a paste made 
by mixing oil of cloves with the oxide of zinc or the powder which 
comes with cement fillings. This paste is anodyne and antiseptic, 
and a pulp will usually remain comfortable under it. It should be 
protected by a filling of gutta-percha or cement. If a pulp has 
begun to suppurate, this paste sealed in with soft gutta-percha is 
an excellent means of keeping the tooth comfortable while the pulp 



288 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

is dying. It may be left in under these conditions for a week or 
two, as the case indicates, and on its removal the canals can ordi- 
narily be cleaned and filled with safety. It will usually be found 
that when a pulp has once become exposed in a deciduous tooth it 
is only a matter of time when it will die. These pulps do not seem 
to be very tenacious of life, and it does not require an application 
of arsenic to kill them. They will often die even under this anti- 
septic paste, but when protected in this way they seldom give the 
slightest discomfort while dying, and the tooth will often remain 
free from pain till it is shed. In other cases it may become some- 
what sore following the death of the pulp, and even end in a small 
abscess opening on the gum; but there is never the intense suffering 
and excessive swelling which sometimes accompanies teeth that are 
neglected and left open to the fluids of the mouth. 

Treatment of Abscessed Deciduous Teeth. 

The canals should be as carefully cleaned as possible by mechani- 
cal means, and then packed with cotton saturated with oil of cloves. 
Some unvulcanized rubber sufficient in size to fill the cavity should 
then be forced down upon the cotton, and compression made on the 
rubber till the oil of cloves comes out at the fistulous opening on 
the gum. When this is accomplished, if the preliminary cleansing 
has been thorough and the contents of the canals have not been too 
offensive, the tooth may be filled at the same sitting. If the den- 
tine seems saturated with foul matter, the canals should be packed 
with cotton and oil of cloves and sealed with gutta-percha for a 
week. If the fistula still remains open at the end of that time, it 
should again be injected with oil of cloves and the tooth filled in 
the following way : The pulp-chamber and canals should be flooded 
with a solution of gutta-percha in eucalyptol, and some temporary 
stopping slightly warmed should be forced down into each canal 
till the eucalyptol solution shows at the opening of the flstula. The 
temporary stopping should be left in the canals as a root-filling, 
and the cavity proper may then be filled with whatever material is 
indicated. 

Following this treatment, these cases will almost invariably heal 



THE MANAGEMENT OF CHILDREN'S TEETH. 289 

and give no further trouble. Indeed, the management of ab- 
scessed deciduous teeth is usually a matter of not much difficulty, 
provided the patient is at all tractable and there is enough of the 
tooth left to work upon. 

The Management of Permanent Teeth in Childhood. 

This is one of the most important problems in the entire practice 
of dentistry. Decay of the teeth has been called essentially a dis- 
ease of youth, and it is undoubtedly true that during childhood it 
seems to make its fiercest attacks. The teeth to suffer most from 
its ravages are accordingly among those which erupt earliest, and 
of these may be mentioned particularly the first permanent molars. 
These teeth should be the object of especial care on the part of the 
dentist. Beyond the fact that they are called upon to do longer 
service in the mouth than any of the other teeth, they have an 
important function in the dental arch which is not often carefully 
enough considered by practitioners. This relates to the time of 
their eruption and to the position they occupy in the arch. To 
them it is given to be the standard-bearers of the jaws during that 
period which intervenes between the loss of the deciduous molars 
and the growth to full length of the bicuspids and second perma- 
nent molars. Without the first permanent molars in their proper 
position at this time the jaws are allowed to drop too close together, 
so that the upper incisors overlap the lower incisors more than is 
normal, and the bicuspids and second molars are never allowed to 
assume their true length and position. This matter of maintain- 
ing the jaws in their proper relation one to the other is very impor- 
tant, as it relates to the symmetry of the face and to the most per- 
fect mastication, and every effort should therefore be made to 
preserve the first permanent molars in their normal length. These 
teeth should be watched from the time of their eruption, and on 
the slightest approach of caries they should be carefully filled. In 
case the patient fails to apply to the dentist till decay has so in- 
volved the teeth that they are badly broken down and not capable 
of maintaining the jaws in their correct position, every effort 

should be made to so build them up with fillings that this function 

19 



290 PRINCIPLES AND PKACTICE OF FILLING TEETH. 

be not lost, and, failing in this, they should be crowned even at this 
earlj age rather than yield them up to the forceps. 

The choice of materials to be used for filling these teeth in the 
early history of their eruption must be governed largely by the 
ability and disposition of the patient to withstand dental operations. 
If decay occurs on the occlusal surface during the period of the 
tooth's eruption through the gum, as is sometimes the case, the 
most serviceable material to check the disease at this time is usually 
cement. It may be employed with less thorough preparation of 
the cavity than is demanded for metal fillings, and it will prove 
effective as a temporary expedient to tide the tooth over this critical 
period till it is fully erupted and in a condition to receive a more 
permanent operation. 

This material may be used in the very earliest stages of decay, 
even when the flap of gum has not entirely receded from the oc- 
clusal surface; and in some mouths where the tendency to decay 
seems to be very great it is well to use it as a preventive by forcing 
it into the grooves and sulci of the occlusal surface before actual 
decay has begun. 

This will often so protect the surface during the eruptive period 
that decay will be avoided. When the occlusal surfaces of the 
teeth of the two jaws so approach each other that they are sub- 
jected to the friction of mastication the tendency to decay is 
thereby materially lessened, and it is consequently a matter of 
much moment to prevent decay till this takes place. The cement 
may conveniently be forced to position by the finger of the opera- 
tor, as was advocated in the treatment of deciduous teeth, and con- 
siderable pressure may be brought to bear upon the filling-material, 
so that every indentation on the occlusal surface is perfectly filled. 
This, while it may not be considered a very elegant method of 
operating, is assuredly a most effective one, and in this instance 
utility is paramount to elegance. 

In cases where occlusal cavities have been filled in this way with 
cement the teeth should be examined every three or four months, 
and metal fillings inserted as soon as the cement wears away and 
the conditions in the mouth make it possible to do more permanent 



THE MANAGEMENT OF CHILDREN'S TEETH. 291 

work. These conditions relate to expediency of operation and to 
the increasing fortitude on the part of the patient to withstand 
the tedium and pain necessary, rather than to any pronounced 
change of structure in the teeth. That a change does take place 
progressively from youth to age is without question, but it is 
neither so radical nor so rapid that it need be accounted an impor- 
tant factor in the selection of a filling-material. Dr. Black has 
shown conclusively that all enamel and all dentine is harder at any 
age than any of our filling-materials, and this should be sufficient 
to settle the question so far as it has a bearing on the choice of ma- 
terial. If tooth-tissue is found which is softer than the materials 
we use it is due to pathological conditions aside from dental caries, 
and need not be considered in this connection. 

As to the choice between gold and amalgam, this should be 
governed by two considerations, — the one of expense and the one 
of an adequate endurance on the part of the patient to submit to 
gold operations without undue nervous strain. It should be the 
aim of all operators who take pride in their work, and who wish to 
do the most permanent service, when they have the care of the 
teeth from childhood, to keep amalgam out of the mouth entirely, 
but this does not seem in all cases to be possible. We must not 
jeopardize the nervous system of our young patients in the blind 
effort to live up to some high ideal, no matter how beautiful it may 
appear to us. ISTeither will it do to affirm that gold should never 
be used under a certain age, say the age of twelve, as we have so 
often heard. It is not a question of age at all. It is a question 
of temperament, a question of physical and mental stamina on the 
part of the patient. Some children at a given age have a much 
greater capacity for enduring operations upon the teeth than have 
other children at the same age, and every operator should make a 
careful study of this matter among his patients. 

A very useful material for filling these occlusal cavities where 
the area of the cavity is not too great is a combination of gold 
foil and tin foil rolled together. This can be used when the gold 
operation would be too exhausting, and if properly manipulated it 
will prove a very satisfactory and often a very permanent opera- 



292 PREsrciPLES and practice of fh.les'g teeth. 

tion. Witli an operator who is familiar with, its manipulation it 
may be inserted so rapidly that it is seldom necessary to apply the 
rubber dam, and this of itself is often an important item in the 
management of children's teeth. It is especially indicated in oc- 
clusal cavities of upper molars and bicuspids, the lower molars 
ordinarily calling for fillings too great in area to make this mate- 
rial serviceable. It cannot be depended upon to wear well in 
cavities with a broad masticating surface. 

There is one point upon first permanent molars which calls for 
the most careful attention in the early period of their eruption, — 
viz, the mesial surface. This surface is in contact with the second 
deciduous molar for several years before the loss of the deciduous 
teeth, and if the tendency to decay is great in that mouth, or if the 
deciduous molar is affected on its distal surface, the first permanent 
molar is almost certain to suffer. It is well in many of these cases, 
as soon as the permanent tooth is fully erupted, to grind away the 
distal surface of the deciduous tooth so that there is only a narrow 
contact between the two., In this way the mesial surface of the 
permanent molar is more readily kept clean. 

In case decay occurs on this surface, it may ordinarily best be 
controlled during the presence of the deciduous teeth with gutta- 
percha. If a sufficient depth of cavity cannot be gained to secure 
the gutta-percha in place, it is best to flow cement over the surface 
as a temporary expedient, though cement on these proximal sur- 
faces must not be depended upcn for any length of service. The 
patient should be instructed to report immediately on the loss of 
the deciduous molar, and whether the permanent tooth has been 
filled with cement or gutta-percha it should at that time be replaced 
with gold. This can be done to better advantage before the erup- 
tion of the second bicuspid, when the mesial surface of the perma- 
nent molar is freely presented to the operator, than at any time 
subsequently. At this sitting e^ery vestige of affected enamel 
should be included in the cavity, and the metallic surface be made 
sufficiently broad to render the operation as permanent as pos- 
sible. 

In cases where the proximal surface is so decayed that the oc- 



THE MAJfAGEMENT OF CHILDREN'S TEETH. 293 

clusal surface becomes involved before the operator's attention 
is called to it, the best temporary filling is ordinarily to be found in 
a combination of gutta-percha and cement, laying gutta-percha 
over the gingival third of the cavity and completing the filling with 
cement. The latter will probably require occasional renewal, but 
the gutta-percha will ordinarily last till the patient is in a condition 
to have gold inserted. 

The care of permanent incisors in the mouths of children is a 
matter calling for careful consideration. If decay occurs very 
early, it is usually best to resort to cement or gutta-percha, instead 
of attempting permanent work at the outset. The choice between 
gutta-percha and cement must be governed by the nature of the 
decay. If there is sufiicient penetration to securely hold the gutta- 
percha in place, it may be depended on for more permanent work 
than cement, but in shallow cavities, too sensitive for much cutting, 
the cement may be maintained in place more readily than gutta- 
percha. Neither of these materials need be considered in the light 
of anything but temporary expedients, and the patient should be 
carefully studied and judiciously schooled toward an attitude of 
sufficient fortitude to submit to gold operations as early as may 
seem practicable. The date at which gold may be substituted for 
the other materials must depend on the sensitiveness of the teeth 
and the ability of the patient to submit to thorough work without 
too much nervous tax. It is folly to attempt to insert gold while 
the patient is so illy under control that perfect work is impossible, 
as it is also wrong to defer longer than necessary the insertion of a 
reliable material like gold and leave the teeth to the mercy of mate- 
rials long since proved to lack permanence. 

In this connection it may be stated that where large cavities 
have occurred in the permanent teeth of children, and where the 
cements and gutta-percha prove unreliable, a very satisfactory 
expedient is found in the use of inlays. It is here that inlays 
appeal to us most strongly. They may be inserted with little 
nervous tax on the patient, and their judicious employment will 
furnish a ready means for managing many of these cases which in 
the past have proved troublesome to control. 



INDEX. 



A 

-'^ PAGE 

Abscessed teeth, treatment of .272 

Amalgam as a filling material, use- 
fulness and limitations of. 161 

Amalgam, manipulation of. 235 

Amalgam, method of packing 237 

Annealer, Custer's Electric 172 

Annealer, Vernon's gas or alcohol..l74 

Annealing gold 169 

Appliances for examining the teeth 48 
Application of the dam in difficult 

cases 77 

Applying the dam for operations on 
buccal, labial, or lingual cavities 7-5 

Approximal trimmere 220 

Arsenic, destroying the pulp with, 

261, 281 
Automatic mallet, the 185 

B 

Bicuiipids and molars, cavities in, 

106, 107, 108, 130, 136 

Bicuspids and molars, clamps for... 57 

Bicuspids and molars, fillings in, 

204, 211, 219, 220, 221 

Bleaching teeth 281 

c 

Calculus, instruments for removal 

of 21 

Calculus, removal of. 19, 25 

Calculus, salivary 13 

Calculus, serumal 15 

Capping pulps, advisability of 254 

Capping i)ulj)S, materials for 257 

Capping pulps, method of 259 

Carbolic acid for sensitive dentine.. 153 
Care of the teeth, instructions to 
patients as to 30 



PAOR 

Caries, dental, etiology of. 33 

Caries, examination of the teeth for 46 
Caries, gelatinous film in connection 

with incipient 35 

Caries, relation of micro-organisms 

to 34, 143 

Caries, susceptibility to, and im- 
munity from 34 

Cataphoresis 153 

Cavities, buccal, labial, and lingual. 130 
Cavities, buccal, labial, and lingual, 
applying the dam for operations 

on 75 

Cavities, buccal, labial, and lingual, 

clamps for 59 

Cavities, classification of 83, 151 

Cavities, occlusal, in bicuspids and 

molars 136 

Cavity formation for inlay fillings..244 

Cavity preparation 83, 85 

Cements for use with porcelain in- 
lays 160, 253 

Cements, use and qualities of as till- 
ing materials 164 

Cements, manipulation of 239 

Cervical clamps for buccal, labial, 

or lingual cavities 59 

Children, management of. 150 

Children's teeth,the management of 283 
Chloro-percha in pulp-canal filling..268 

Clamps, selection of 57 

Classification and preparation of 

cavities 83, 85 

Cleanliness a preventative of decay 31 
Cocaine, removal of the pulp with..264 
Cohesive and non-cohesive gold. ..168 

Copper, oxyphosphate of. 165 

Cotton rolls, the use of 81, 83 

Crystal golds 177 

Crowning versus contouring 105 

296 



296 



INDEX. 



^ PAGE 

Deciduous teeth, management of 

the 283 

Deciduous teeth, treatment of ab- 
scessed , 288 

Deciduous teeth, treatment of ex- 
posed pulps in 287 

Dental caries, etiology of 33 

Dental caries, susceptibility to and 

immunity from 34 

Dentine, hypersensitive 146 

Dentine, secondary 145 

Dentine, treatment of softened, in 

deep-seated cavi ties 1 42 

Dentine, recalcification of. 143 

Deposits on the teeth 11 

Deposits on the teeth, classification of 13 
Deposits on the teeth, removal of... 19 
Destroying the pulp with arsenic, 

261, 281 

Destruction of the pulp 260 

Detail of cavity formation in prox- 
imal cavities in anterior teeth 

involving the incisal angle 101 

Detail of cavity formation in prox- 
imo-occlusal cavities in bicuspids 

and molars 121 

Detail of cavity formation in simple 
proximal cavities in incisors and 

cuspids 91 

Different forms of gold 175 

Discoloration of pulpless teeth, to 

prevent 281 

Disto-occlusal fillings in bicuspids 

and molars 211, 219 

Drilling out pulp-canals 274 

E 

Electric annealer for gold 172 

Electric mallet, the 187 

Enamel, variation in structure of... 42 
Examinations of the teeth for caries 46 
Examining the teeth, appliances for 48 
Exclusion of moisture during oper- 
ations , 49 

Exploring instruments... 48 

Extension for prevention 86, 92, 109 



-^ PAGE 

Filled teeth, opening into, where the 
pulps have died but lain dormant. 280 

Filling materials, characteristics of.. 154 

Filling pulp-canals 268 

Fillings, buccal, labial, andlingual..227 

Fillings, disto-occlusal, in bicuspids 
and molars 211, 219 

Fillings, finishing buccal, labial, 
and lingual 228 

Fillings, occlusal, in bicuspids and 
molars 221 

Fillings, finishing occlusal, in bi- 
cuspids and molars 226 

Fillings, finishing proximal, in in- 
cisors 200 

Fillings, proximo-occlusal in bicus- 
pids and molars 214 

Floss silk, use of. 31, 48 

G 

Gelatinous film in connection with 

incipient caries 35 

Gold, advantages and disadvantages 

of as a filling material 155 

Gold, annealing 169 

Gold and its combinations 155, 159 

Gold and iridium 161 

Gold and platinum 159 

Gold and tin 160 

Gold, cohesive and non-cohesive 168 

Gold, cohesiveness of destroyed by 

over-m alletin g 185 

Gold, diff"erent forms of 175 

Gold fillings, the introduction, con- 
densation, and finishing of 193 

Gold inlays 167, 252 

Green stain 17 

Gum, absorption of due to presence 

of calculus , 12 

Gum depressor, use of 66 

Gutta-percha as a filling material, 

advantages and limitations of 165 

Gutta-percha for capping pulps 258 

Gutta-percha for filling pulp-canals. 268 

Gutta-percha for wedging 89, 119 

Gutta-percha, manipulation of. 242 



INDEX. 



297 



-ti PAGE 

Hand mallet, the 179 

Hand pressure indispensable in cer- 
tain locations 188 

Hand pressure compared with mallet 
force 190 

High-fusing and low-fusing porce- 
lains 248 

Hypersensitive dentine 146 



Incisors and cuspids, proximal cavi- 
ties in 85 

Inlays, advantages and limitations of 166 
Inlaj's in permanent teeth of chil- 
dren 293 

Inlays, gold 167, 252 

Inlays, porcelain 166, 243 

Instruction to patients as to the care 

of the teeth 30 

Instruments for the removal of cal- 
culus.. 21 

Instruments for removal of the pulp. 265 

Interproximal space, the 114 

Introductory 7 

Iridium, gold and 161 

J 

Jaws, force exerted by in mastica- 
tion 109, 129, 222 



Ligatures, use of. 61 

M 

Mallet, the electric 187 

Mallets and malleting 179 

Mallets, automatic 185 

Mallets, experiments to determine 

the relative condensing power of,.l 81 

Management of children's teeth 283 

Management of permanent teeth in 

childhood 289 

Management of pulpless teeth to 

prevent discoloration 281 

Manipulation of amalgam 235 

Manipulation of cements 239 



Manipulation of gutta-percha 242 

Manipulation of platinum and gold. 229 

Manipulation of tin and gold 231 

Manner of applying the dam in the 

different locations in the mouth... 68 
Mastication, force exerted in, 

109, 129, 222 

Materials for capping pulps 257 

Matrices for special cases 209 

Matrix, advantages and limitations 

of the 204 

Matrix, fitting the, for inlays 245 

Matrix, manner of using the 209 

Matrix, objections to the use of 205 

Mercury, amount required in amal- 
gam 235 

Method of capping pulps 259 

Method of packing amalgam 237 

Micro-organisms, their relation to 

caries 34, 143 

Moisture, exclusion of, during 

operations 49 

Mouth-mirror, use of. 48 

Napkins, the use of 51, 81 

Nausea from the use of rubber 
dam, to overcome 52 

o 

Occlusal cavities in bicuspids and 
molars 136 

Occlusal fillings in bicuspids and 
molars 221 

Occlusal fillings in bicuspids and 
molars, finishing 226 

Opening into filled teeth in which 
the pulps have died and lain 
dormant : 280 

Oxychloride of zinc 164 

Oxyj)hosphate of copper 165 

Oxyphosphate of zinc 165 



Peridental membrane, irnpairmentof 
following destruction of the pulp. 263 



298 



INDEX. 



PAGE 

Peridental membrane, protection to 

in malleting 190 

Platinum and gold, manipulation of. 229 

Pluggers, the choice of..., 198, 215 

Porcelain bodies for inlays 248 

Porcelain inlays 166, 243 

Porcelain inlays, baking of. 250 

Porcelain inlays in permanent teeth 

of children ...293 

Porcelain inlays, manipulation of 

materials 251 

Porcelain inlays, matching shades 

with 249 

Preface to the second edition 3 

Pressure anesthesia for removal of 

the pulp 264, 281 

Proximal cavities in anterior teeth 

involving the incisal angle 100 

Proximal cavities in incisors and 

cuspids, simple 85 

Proximal cavities in bicuspids and 

molars 106 

Proximal fillings in anterior teeth 

involving the incisal angle 202 

Proximal gold fillings in incisors, 

simple 194 

Proximo-occlusal cavities in bicus- 
pids and molars 108 

Proximo-occlusal fillings in bicus- 
pids and molars 204 

Pulp-canals, filling. 268 

Pulp capping 254 

Pulp, destruction of the 260 

Pulp, removal of the, with cocaine. 264 
Pulpless teeth, treatment of. 271 

R 

Kecalcification of dentine 143 

Eapid mallets 186 

Eemoval of calculus, instruments 

for 21 

Eemoval of salivary calculus 19 

Eemoval of serumal calculus 25 

Removal of stains from the teeth... 28 
Eemoval of the pulp with cocaine..264 
Eolls, cotton 81, 83 



PAGE- 

Eubber-dam, application of, for op- 
erations on buccal, labial, and 

lingual cavities 75 

Eubber-dam, application of in diffi- 
cult cases 77 

Eubber-dam clamps 55 

Eubber-dam, kinds of. 52 

Eubber-dam, method of applying 

in diff"erent locations in the mouth 68 
Eubber-dam, nausea from use of.... 52 

Eubber-dam, punching holes in 53. 

Eubber for wedging..." 88 

s 

Saliva, exclusion of during opera- 
tions , 50' 

Salivary calculus, nature of. 13 

Salivary calculus, removal of. 19 

Sensitive dentine, treatment of. 146 

Separating the teeth 119' 

Serumal calculus, nature of. 15 

Serumal calculus, removal of 25 

Simple proximal cavities in bicus- 
pids and molars ..106 

Simple proximal cavities in incisors 

and cuspids 85 

Simple proximal gold fillings in in- 
cisors 194 

Size of rubber-dam 53 

Softened dentine, treatment of 142 

Stains on the teeth, nature of. 17 

Stains on the teeth, removal of 28 

Sulphuric acid in treating pulp- 
canals 275 

T 

Tin as a filling material 164 

Tin and gold, manipulation of. 231 

Tobacco smoke, effect of, on the 

teeth 15, 18 

Tooth-brush, proper use of the 30 

Tooth-picks, use of. 32 

Treatment of abscessed deciduous 

teeth 288 

Treatment of exposed pulps in de- 
ciduous teeth 287 



INDEX. 



299 



Treatment of pulpless teeth having 
a fistulous opening on the gum... 278 

Treatment of pulpless teeth where 
the canals have been long exposed 
to the fluids of the mouth, but 
where there is no fistulous open- 
ing 272 

Treatment of softened dentine in 
deep-seated cavities 142 

Y 

Vaseline on finishing disks 228 

Vaseline as a lubricant for rubber- 
dam 79 

"Vulnerable point," the gingival 
margin as 91 



w 

PAGE 

Waxed floss silk ligatures 63 

Waxed linen tape for wedging 89 

Wedging to gain space 88 

Wooden wedges for separating 90 



Zinc, oxychloride of, as a filling 
material 164 

Zinc, oxychloride of, for capping 
pulps 258 

Zinc, oxyphosphate of, as a filling 
material 165 

Zinc, oxyphosphate of, for capping 
pulps 259 






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